Submitted: 14 March 2020
Accepted: 20 July 2020
Published online: 5 January, TAPS 2021, 6(1), 30-39
https://doi.org/10.29060/TAPS.2021-6-1/OA2235

Yit Shiang Lui, Abigail HY Loh, Tji Tjian Chee, Jia Ying Teng, John Chee Meng Wong & Celine Hsia Jia Wong

Department of Psychological Medicine, National University Health System, Singapore

Abstract

Introduction: A good understanding of basic child-and-adolescent psychiatry (CAP) is important for general medical practice. The undergraduate psychiatry teaching programme included various adult and CAP topics within a six-week time frame. A team of psychiatry tutors developed two new teaching formats for CAP and obtained feedback from the students about these teaching activities.

Methods: Medical students were introduced to CAP via small group teaching in two different modes. One mode was the “Clinical Vignettes Tutorial” (CVT) and the other mode “Observed Clinical Interview Tutorial” (OCIT). In CVT, tutors would discuss clinical vignettes of real patients with the students, followed by explanations about theoretical concepts and management strategies. OCIT involved simulated-patients (SPs) who assisted by acting as patients presenting with problems related to CAP, or as parents for such patients. At each session, students were given the opportunity to interview “patients” and “parents”. Feedback was given following these interviews. The students then completed surveys about the teaching methods.

Results: Students rated very-positive feedback for the teaching of CAP in small groups. Almost all found these small groups enjoyable and that it helped them apply what they had learnt. Majority agreed that the OCIT sessions increased their level of confidence in speaking with adolescents and parents. Some students agreed that these sessions had stimulated their interest to know more about CAP.

Conclusion: Small group teaching in an interactive manner enhanced teaching effectiveness. Participants reported a greater degree of interest towards CAP, and enhanced confidence in treating youths with mental health issues as well as engaging their parents.

Keywords:           Child Adolescent Psychiatry, Medical Education, Small Group, Teaching

Practice Highlights

• Psychiatric disorders are among the most common medical conditions experienced by children and adolescents, and data from the Singapore Mental Health survey conducted in 2010 had shown the prevalence rates of emotional and behavioural problems among Singaporean youth to be at 12.5%.
• Most medical students had limited exposure to Child & Adolescent Psychiatry (CAP) in their medical curriculum due to reduced proportions of teaching time and opportune clinical exposures allocated to CAP programmes.
• This would be further compounded by the limited number of child and adolescent psychiatrists involved in teaching at medical schools and supervising clinical postings.
• This manuscript described synergistic teaching methods employed in educating medical students within the field of Child & Adolescent Psychiatry and examined the effectiveness and acceptability of CAP teaching using small-group teaching classes.
• The CAP small group interactive teaching sessions for medical students received good feedback from majority of the participants and translated to applicability and skillsets transferability.

Figure. 1. Open comment feedback to the survey question “The best things about the sessions were…”

In areas that the students indicated for further improvement, they had cited for a “shorter” duration in each teaching session (Figure 2). This was likely due to the nature of a full day programme of CAP teaching which could last eight hours in a day with a one-hour lunch break. Others had shared that they preferred “smaller” groups so students could get more chances to practice interviewing the SPs and also be provided “more time for discussion” to allow more in-depth feedback as well as discussion of each clinical condition. Some students remarked that Objective Structured Clinical Examination (OSCE) styled marking schemes could help enhance their learning experiences as this method might be more structured, compared to an open discussion.

Figure 2. Open comment feedback to the survey question “Some ways which I think can make the sessions better are…”

IV. DISCUSSION

This study evaluated the effectiveness and acceptability of small group tutorials for CAP conditions, which are packaged inseparably as part of a medical undergraduate psychiatry teaching programme. CVT and OCIT are synergistically designed to complement each other in the curriculum. The surveys used to compile the medical undergraduates’ responses had focused on their learning experience with the CAP curriculum. The effectiveness of the teaching methods namely CVT and OCIT would be determined from transferability of the requisite knowledge base and the clinical skills, as well as availability of opportunities to experience interviewing for the participants. The survey responses were also used to gauge the performance of the SPs and the clinical tutors’ usefulness. In addition, the degree of how impactful the teaching sessions had in generating interest towards CAP was also evaluated.

The fourth-year medical students gave good feedback for the small group teaching sessions. They reported that the CVT were enjoyable, beneficial and had allowed them to apply what they had learnt. For the OCIT, most of the respondents indicated that the session had helped them to learn psychiatric interviewing skills, increased their level of confidence in speaking with adolescents and parents, and had helped them to apply in clinical scenarios what they had learnt. There is discernible difference between the feedback for CVT and OCIT. The students’ feedback for CVT affirmed applicability of the knowledge content of CAP whereas those for OCIT concurred with transferability of interviewing skills in terms of confidence level.  

In the open feedback segment of the survey, respondents reported that they had particularly liked the interactive and hands-on aspect of the session, the frequent opportunities for evaluation and feedback, as well as for practice. However, they highlighted that certain factors such as the size of grouping, the length of the sessions and random allocation of conditions could be improved further to enhance their learning experience. Overall, their feedback still indicated positive experiences in these small group sessions, and this translated to an increased knowledge base, a heightened level of confidence, and burgeoned interest in CAP among the student participants.

This study’s limitations included the challenges inherent with attempting to accurately assess the students’ genuine experiences and feelings towards the sessions; with possible biases (recall and Hawthorne effect) in responding to questionnaires; and the lack of correlation to actual performances in real-world settings. Furthermore, what remained unanswered was how such sessions might truly generate interest leading to possibly pursuit of a career in CAP. In addition, it is uncertain whether changing the teaching methods with the curriculum could inspire more medical students and young doctors to consider specialising in this field and raise the number of residency applications. The data from our study did appear to be consistent with findings from other CAP clinical teaching programmes. In these programmes, more exposure to CAP and increased clinical opportunities did correlate with changes in impressions towards and appreciation of clinical interactions with children, increased positive views of CAP as part of medical practice, and heightened interest in CAP as a field of medical specialty (Dingle, 2010; Kaplan & Lake, 2008; Malloy et al., 2008; Martin, Bennett, & Pitale, 2005).

In the current undergraduate medical curriculum, the amount of time allocated to teaching CAP is relatively small compared to other topics. Child and adolescent psychiatric cases can be particularly complex and their management demand sensitive handling, which may pose challenges to real world practice. Youth patients and their parents may value privacy and sometimes do not allow medical students to be involved in initial assessments and subsequent follow-up consultations. These factors collectively pose unique challenges to teaching and equipping medical students with the skills and knowledge to address child and adolescent mental health disorders. While clinical contact and patient experience would be preferred and desirable for training, it may be impractical given the various constraints mentioned above (Kaplan & Lake, 2008). Hence, other creative methods of “exposure” to CAP patients should be incorporated into teaching rotations to offer medical students the opportunities to expand this knowledge base, apply the knowledge to practice scenarios, and further their clinical and communication skills. Small group sessions such as the CVTs and OCITs are teaching activities that can be used to overcome some of these challenges.

Our study showed that small group interactive teaching is effective in helping medical students to apply what they have learnt about CAP, increase their confidence in speaking to adolescents as patients and learn psychiatric interviewing skills. It also exposes them to a wide range of relevant CAP cases to which they can apply their theoretical knowledge and practice interview and management techniques. Furthermore, we have found that all this can be adequately achieved in a tailored environment that is conducive for learning. The collective constructive feedback had been used to further improve the content and deliverability style so as to enhance implementation in future batches. It has also been conceptualised to compare CVT and OCIT as individual teaching methods for future scholarly research.

V. CONCLUSION

The CAP small group interactive teaching sessions for medical students received good feedback from majority of the participants. This positive validation would spur the authors on to explore further how this pedagogy could help spark interests in Child and Adolescent Psychiatry among medical students given the shortfall of child and adolescent psychiatrists worldwide.

Notes on Contributors

AHYL analysed and interpreted data. CHJW, together with TJY and JCMW planned and conducted the child psychiatry small group teaching and collected feedback data from the medical students. TJY developed the feedback questionnaire. YSL, together with AHYL, CHJW and TTC planned and wrote the manuscript. All authors read and approved the final manuscript.

Ethical Approval

NHG DSRB reference number 2019/00431 for exemption.

Data Availability

Datasets generated and/or analysed during the current study are available from corresponding author on reasonable request.

Acknowledgements

The authors wish to thank the team from Centre for Healthcare Simulation, Yong Loo Lin School of Medicine, National University of Singapore for the invaluable support in recruiting and training the simulated patients for the CAP teaching program. We appreciate the participation of the simulated patients and medical students in the teaching programme.

Funding

There is no funding for this paper.

Declaration of Interest

As far as all the authors are concerned, we do not know of, or foresee any future competing interests. We are not aware of any issues relating to journal policies in submitting this manuscript. All the authors have approved of the manuscript for submission. The authors declare that they have no competing interests.

References

Baranne, M. L., & Falissard, B. (2018). Global burden of mental disorders among children aged 5–14 years. Child and Adolescent Psychiatry and Mental Health, 12(1), 19.

Breton, J. J., Plante, M. A., & St-Georges, M. (2005). Challenges facing child psychiatry in Quebec at the dawn of the 21st Century. The Canadian Journal of Psychiatry, 50(4), 203-212.

Costello, E. J., Egger, H., & Angold, A. (2005). 10-year research update review: The epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. Journal of the American Academy of Child & Adolescent Psychiatry, 44(10), 972-986.

Dingle, A. D. (2010). Child psychiatry: What are we teaching medical students? Academic Psychiatry, 34(3), 175-182.

Erskine, H. E., Moffitt, T. E., Copeland, W. E., Costello, E. J., Ferrari, A. J., Patton, G., … & Scott, J. G. (2015). A heavy burden on young minds: The global burden of mental and substance use disorders in children and youth. Psychological Medicine, 45(7), 1551-1563.

Hunt, J., Barrett, R., Grapentine, W. L., Liguori, G., & Trivedi, H. K. (2008). Exposure to child and adolescent psychiatry for medical students: Are there optimal “teaching perspectives”?. Academic Psychiatry, 32(5), 357-361.

Kaplan, J. S., & Lake, M. (2008). Exposing medical students to child and adolescent psychiatry: A case-based seminar. Academic Psychiatry, 32(5), 362-365.

Kyu, H. H., Pinho, C., Wagner, J. A., Brown, J. C., Bertozzi-Villa, A., Charlson, F. J., … & Fitzmaurice, C. (2016). Global and national burden of diseases and injuries among children and adolescents between 1990 and 2013: Findings from the global burden of disease 2013 study. JAMA Pediatrics, 170(3), 267-287.

Lim, C. G., Ong, S. H., Chin, C. H., & Fung, D. S. S. (2015). Child and adolescent psychiatry services in Singapore. Child and Adolescent Psychiatry and Mental Health, 9(1), 7.

Malloy, E., Hollar, D., & Lindsey, B. A. (2008). Increasing interest in child and adolescent psychiatry in the third-year clerkship: Results from a post-clerkship survey. Academic Psychiatry, 32(5), 350-356.

Martin, V. L., Bennett, D. S., & Pitale, M. (2005). Medical students’ perceptions of child psychiatry: Pre-and post-psychiatry clerkship. Academic Psychiatry, 29(4), 362-367.

Plan, S. (2002). A Call to Action: Children Need Our Help! American Academy of Child & Adolescent Psychiatry. Retrieved from https://www.aacap.org/app_themes/aacap/docs/resources_for_primary_care/workforce_issues/AACAP_Call_to_Action.pdf

Sawyer, M., & Giesen, F. (2007). Undergraduate teaching of child and adolescent psychiatry in Australia: Survey of current practice. Australian & New Zealand Journal of Psychiatry, 41(8), 675-681.

Thomas, C. R., & Holzer, C. E., 3rd (2006). The continuing shortage of child and adolescent psychiatrists. Journal of the American Academy of Child & Adolescent Psychiatry, 45(9), 1023-1031.

World Health Organization. (2014). Adolescent health epidemiology. Retrieved from http://www.who.int/maternal_child_adolescent/epidemiology/adolescence/en/

*Yit Shiang Lui
1E Kent Ridge Road
Tower Block, Level 9,
Singapore 119228
Tel: 6772 6331
Email address: yit_shiang_lui@nuhs.edu.sg

Submitted: 14 February 2020
Accepted: 1 July 2020
Published online: 5 January, TAPS 2021, 6(1), 40-48
https://doi.org/10.29060/TAPS.2021-6-1/OA2227

Shirley Beng Suat Ooi^1,2, Clement Woon Teck Tan^3,4 & Janneke M. Frambach⁵

¹Emergency Medicine Department, National University Hospital, National University Health System, Singapore; ²Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of Ophthalmology, National University Hospital, National University Health System, Singapore; ⁴Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ⁵School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands

Abstract

Introduction: Almost all published literature on effective clinical teachers were from western countries and only two compared medical students with residents. Hence, this study aims to explore the perceived characteristics of effective clinical teachers among medical students compared to residents graduating from an Asian medical school, and specifically whether there are differences between cognitive and non-cognitive domain skills, to inform faculty development.

Methods: This qualitative study was conducted at the National University Health System (NUHS), Singapore involving six final year medical students at the National University of Singapore, and six residents from the NUHS Residency programme. Analysis of the semi-structured one-on-one interviews was done using a 3-step approach based on principles of Grounded Theory.

Results: There are differences in the perceptions of effective clinical teachers between medical students and residents. Medical students valued a more didactic spoon-feeding type of teacher in their earlier clinical years. However final year medical students and residents valued feedback and role-modelling at clinical practice. The top two characteristics of approachability and passion for teaching are in the non-cognitive domains. These seem foundational and lead to the acquisition of effective teaching skills such as the ability to simplify complex concepts and creating a conducive learning environment. Being exam-oriented is a new characteristic not identified before in “Western-dominated” publications.

Conclusion: The results of this study will help to inform educators of the differences in a learner’s needs at different stages of their clinical development and to potentially adapt their teaching styles.

Keywords:           Clinical Teachers, Medical Students, Residents, Cognitive/Non-Cognitive, Asian Healthcare, Faculty Development

Practice Highlights

• Approachability and teaching passion are foundational non-cognitive skills in effective clinical teachers.
• These foundational skills are more important for undergraduate than postgraduate teaching.
• Procedural residents can accept less ‘warm’ teachers if they can learn advanced clinical skills.
• Medical students value didactic ‘spoon-feeding’ type of teachers in their earlier clinical years.
• Final year medical students and residents value feedback and role-modelling at clinical practice.

I. INTRODUCTION

“The transformation of our students requires the engagement of innovative and outstanding clinician-teachers who not only supervise students in their development of technical skills and applied knowledge but also serve as role models of the values and attributes of the profession and of the life of a professional” (Sutkin, Wagner, Harris, & Schiffer, 2008). This statement nicely encapsulates the very important role played by outstanding clinical teachers in helping students to ultimately become professionals with the attributes our healthcare system desires. Previous research has extensively investigated characteristics of effective clinical teachers to inform faculty development (e.g. Branch, Osterberg, & Weil, 2015; Hatem et al., 2011; Hillard, 1990; Kernan, Lee, Stone, Freudigman, & O’Connor, 2000; Paukert & Richards, 2000; Singh et al., 2013; Sutkin et al., 2008; White & Anderson, 1995). However, despite the large body of existing research on effective clinical teaching, two issues related to the needs of different groups of learners need further investigation to enable more tailored faculty development.

First, effective clinical teaching may look different in undergraduate as compared with postgraduate education. In many healthcare institutions, clinical teachers are expected to teach across the medical education continuum, i.e., undergraduate medical students, graduate doctors in training, as well as part of continuing medical education, and teaching abilities are a necessary prerequisite in an academic environment (Hatem et al., 2011). Based on the conceptual framework of constructivism (Bednar, Cunningham, Duffy, & Perry, 1991)—­a theory which equates learning with creating meaning from experience or contextual learning­—Jonassen (1991) argues that constructive learning environments are most effective for acquiring knowledge in the advanced stage of knowledge, the stage between introductory and expert. According to Jonassen (1991), the initial or introductory stage of knowledge acquisition occurs when learners have very little directly transferable prior knowledge about a skill or content area. In this stage, knowledge is best acquired through more objectivistic approaches which can be described as ‘spoon-feeding’. Medical students in general would fit into this introductory stage, in varying degrees depending on their seniority and individual progress in learning. Jonassen’s (1991) second stage is advanced knowledge acquisition where the domains are ill-structured and more knowledge-based. This is in contrast to his third or final stage of knowledge acquisition of experts that require very little instructional support but are able to deal with elaborate structures, schematic patterns and seeing the interconnectedness in knowledge through experience. The stage of junior doctors in training would be fit into the second or advanced stage of learning. Constructivist teachers help students construct knowledge to become active learners rather than passive recipients of knowledge from the teachers or textbooks. In view of this constructivist framework, it appears logical to postulate that as medical students mature to become practicing doctors, their perceptions of effective clinical teachers may change from one who ‘spoon-feeds’ them with medical knowledge to one who encourages them to actively construct new meaning as they become clinically more experienced and have to deal with complex and ill-defined problems. Low, Khoo, Kuan, and Ooi (2020) showed that although the top four characteristics of effective medical teachers are consistent across all 5 years of medical school, characteristics that facilitate active learner participation are emphasised in the clinical years consistent with constructivist learning theory. However, as there is a paucity of comparative research on perceptions of effective clinical teachers among undergraduates as compared to postgraduates to plan more focused faculty development to address the attributes the learners look for in their clinical teachers, this warrants further research.

The second issue relates to potential differences in the clinical teaching role between Asian and Western settings. In Western studies, as noted above, effective clinical teachers are encouraged to stimulate students’ intellectual curiosity leading to more self-directed learning (Hillard, 1990; Kernan et al., 2000; White & Anderson, 1995). In contrast, feelings of uncertainty about the independence required in self-directed learning, a focus on tradition that respects ‘old ways’, hierarchy expecting ‘truths’ to come from persons of higher status, and an achievement orientation to pass and excel in examinations have been identified as more prominent in non-Western than in Western cultures (Frambach, Driessen, Chan, & van der Vleuten, 2012). This is despite the recent introductions of more student-centred education methods. In Singapore for example, there is a move in the Yong Loo Lin School of Medicine (YLLSoM) to try to embed students into healthcare teams (Jacobs & Samarasekera, 2012) and implement newer methods of learning such as flipped classroom. However, many teachers still employ traditional methods of lectures and small group tutorials focused on exam preparation. A comprehensive review study of 68 articles on effective clinical teaching (Sutkin et al., 2008), comprised only one article that reported research from a non-Western setting (Elzubeir & Rizk, 2001). In this article, originating from the United Arab Emirates, there is no discussion on whether there is a difference in the perception of a role model between medical students in Asian countries compared to the West (Elzubeir & Rizk, 2001). Another study conducted in Asia showed differences in the perceptions of first-year and fifth-year medical students in Singapore on what makes an effective medical teacher (Kua, Voon, Tan, & Goh, 2006). More first-year students preferred handouts in contrast to fifth-year students who were less reliant on ‘spoon-feeding’. Research on effective clinical teaching is growing in the Asian setting (Ciraj et al., 2013;  Haider, Snead, & Bari, 2016; Kikukawa et al., 2013; Mohan & Chia, 2017; Nishiya et al., 2019; Venkataramani et al., 2016) though there is still a paucity of literature in the Asian setting compared with studies conducted in the West and there are none that directly compared medical students with residents.

Another issue that deserves further attention is the role of non-cognitive domain skills in clinical teaching. Sutkin et al.’s (2008) review study described three main categories of characteristics of good clinical teachers: 1) physician characteristics, 2) teacher characteristics, and 3) human characteristics (Table 1). Approximately two-thirds of the characteristics were in non-cognitive domains (such as those involving relationship skills, emotional states, and personality types), and one-third in cognitive domains (such as those involving reasoning, memory, judgment, perception, and procedural skills). The article noted that cognitive abilities can be taught and learned, in contrast to non-cognitive attributes which are more difficult to develop and teach. Faculty development programmes currently often focus on traditional cognitive skills, such as curriculum design, large-group teaching, and assessment of learners (Searle, Hatem, Perkowski, & Wilkerson, 2006). In contrast, if non-cognitive domains are more important in contributing to outstanding teaching, they might need greater emphasis in the curricula of these workshops. The good news is that according to Schiffer, Rao, and Fogel (2003), non-cognitive behaviours are both measurable and alterable. Most of them have underlying neural networks which are entering our sphere of understanding. Hence non-cognitive skills, although much more challenging to develop than cognitive skills, have a potential to be developed. It is not clear whether there are differences in the distribution between cognitive and non-cognitive domains skills between the perceptions of medical students compared to residents of an effective clinical teacher.

The aim of this qualitative study is to explore the perceived characteristics of an effective clinical teacher among medical students compared to residents graduating from an Asian medical school and whether there is a difference regarding cognitive and non-cognitive domain skills.

II. METHODS

A. Participants

The participants consisted of final/fifth year medical students (M5s) from the Yong Loo Lin School of Medicine (YLLSoM), National University of Singapore (NUS) who were posted to the National University Hospital (NUH) to do their student internship posting in 2016. To ensure sufficient working experience, the National University Health System (NUHS) residents who had graduated from the YLLSoM and who had recently completed their intermediate specialty examinations were recruited. These were third to fifth year residents in different programmes. Maximal variation sampling of the M5s and the residents of both gender, different ethnic groups and from different specialties (for residents only) was done.

B. Design

A pragmatic qualitative research design (Savin-Baden & Howell Major, 2013) was used to get the participants to reflect on their own learning journey affecting their perceptions of the qualities that make an effective clinical teacher from the time they were first exposed to clinical medicine in year 3 (M3) of medical school to final year (M5) for the students, and to residency for the residents.

 C. Data Collection

Semi-structured one-on-one interviews using open-ended questions were conducted. A list of M5s doing their student internship programme in the various departments in NUH was invited via an e-mail invitation to participate in this study. To ensure maximal variation sampling, M5s of both gender and as far as possible different ethnic groups were recruited. As for the residents, through the Graduate Medicine Education Office in NUH, residents of both gender, from different ethnic groups and different specialties (both procedural and non-procedural) were selected from those who responded voluntarily to the invitation to participate in this study to ensure maximal variation sampling as residents from procedural specialties may have different perceptions of effective clinical teachers from non-procedural specialties.

Written consent after reading the Participant Information Sheet was taken from the interviewees before the interview was conducted in a quiet room. The interview was audiotaped and lasted between 30 and 45 minutes.

D. Data Analysis

The audiotaped interviews were transcribed. As all the 12 interviews were conducted by the principal investigator (PI) (SO) and although the coding and official analysis of the interviews were done after all the 12 interviews were transcribed, the PI had taken note of themes emerging and decided on ending the interviews after no substantial new themes had emerged.

In the first phase, open coding, initial categories of the information on characteristics of effective clinical teachers by segmenting information and assigning open codes were formed. In the second coding phase, broader categories were developed through conceptually related ideas. The third phase involved selective coding where the individual categories were counterchecked with Sutkin et al.’s (2008) categories of teacher, physician and human characteristics and whether they were in the cognitive or non-cognitive domains (Table 1). Further related categories according to Sutkin et al.’s (2008) classification were brought together.

Physician Characteristics

Submitted: 15 April 2020
Accepted: 5 June 2020
Published online: 5 January, TAPS 2021, 6(1), 49-59
https://doi.org/10.29060/TAPS.2021-6-1/OA2248

Amaya Tharindi Ellawala¹, Madawa Chandratilake² & Nilanthi de Silva²

¹Department of Medical Education, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka; ²Faculty of Medicine, University of Kelaniya, Sri Lanka

Abstract

Introduction: Professionalism is a context-specific entity, and should be defined in relation to a country’s socio-cultural backdrop. This study aimed to develop a framework of medical professionalism relevant to the Sri Lankan context.

Methods: An online Delphi study was conducted with local stakeholders of healthcare, to achieve consensus on the essential attributes of professionalism for a doctor in Sri Lanka. These were built into a framework of professionalism using qualitative and quantitative methods.

Results: Forty-six attributes of professionalism were identified as essential, based on Content Validity Index supplemented by Kappa ratings. ‘Possessing adequate knowledge and skills’, ‘displaying a sense of responsibility’ and ‘being compassionate and caring’ emerged as the highest rated items. The proposed framework has three domains: professionalism as an individual, professionalism in interactions with patients and co-workers and professionalism in fulfilling expectations of the profession and society, and displays certain characteristics unique to the local context.

Conclusion: This study enabled the development of a culturally relevant, conceptual framework of professionalism as grounded in the views of multiple stakeholders of healthcare in Sri Lanka, and prioritisation of the most essential attributes.

Keywords:           Professionalism, Culture, Consensus

Practice Highlights

• Medical professionalism is recognised as a culturally dependent entity.
• This has led to the emergence of definitions unique to socio-cultural settings.
• List-based definitions provide operationalisable means of portraying its meaning.
• A Delphi study was conducted to achieve consensus on locally relevant professionalism attributes.
• Using quantitative and qualitative methods, a conceptual framework of professionalism was developed.

I. INTRODUCTION

There is no single definition of medical professionalism that encompasses its many subtle nuances (Birden et al., 2014).  The realisation that professionalism is a dynamic, multi-dimensional entity (Van de Camp, Vernooij-Dassen, Grol, & Bottema, 2004), significantly dependent on context (Van Mook et al., 2009), and cultural backdrop (Chandratilake, Mcaleer, & Gibson, 2012), has led to the emergence of definitions specific to cultures and socio-economic backgrounds.

Many of the current definitions originate from Western societies. Certain Eastern cultures have embraced such definitions, though they are undeniably in conflict with local traditional views (Pan, Norris, Liang, Li, & Ho, 2013). In parallel however, countries such as Egypt, Saudi Arabia, Japan, China and Taiwan have explored how professionalism is conceptualised within their contexts (Al-Eraky, Chandratilake, Wajid, Donkers, & Van Merrienboer, 2014; Leung, Hsu, & Hui, 2012; Pan et al., 2013). Such studies have portrayed the interplay between cultural, socio-economic and religious factors in shaping perceptions on professionalism, further fuelling the notion that professionalism must be “interpreted in view of local traditions and ethos” (Al-Eraky et al., 2014, p. 14).

Culture is the embodiment of elements such as attitudes, beliefs and values that are shared among individuals of a community and is therefore, an entity that distinguishes one group of people from another (Hofstede, 2011). Various cultural theories provide insight into inter-cultural differences across the globe (Hofstede, n.d.; Schwartz, 1999). The Sri Lankan cultural context, while aligned with those of its closest geographical neighbours in South Asia in some ways, differs from them in other important aspects. 

Certain attempts have been made to explore the meaning of professionalism in Sri Lanka. Chandratilake et al. (2012) provided a degree of insight while comparing cultural similarities and dissonances in conceptualising professionalism among doctors of several nations. Monrouxe, Chandratilake, Gosselin, Rees, and Ho (2017) built on this work with their analysis of professionalism as viewed by local medical students. The sole regulatory authority of the medical profession in the country, the Sri Lanka Medical Council (SLMC, 2009) has delineated what it expects in terms of professionalism, by outlining the constituents of ‘good medical practice’, many of which converge with elements of professionalism described in the literature.

While the work mentioned here has shed some light on the topic, to our knowledge, there were no studies that focused solely on the local conceptualisation of professionalism, drawing on the views of diverse stakeholders of healthcare.

There exist two schools of thought on how professionalism can be defined: as a list of desirable attributes (Lesser et al., 2010), or as an over-arching, value-laden entity that transcends such lists (Irby & Hamstra, 2016; Wynia, Papadakis, Sullivan, & Hafferty, 2014). Unlike the latter, a list may not address the “foundational purpose of professionalism” (Wynia et al., 2014, p. 712); however, it will provide a tangible, operationalisable portrayal (Lesser et al., 2010). It is possibly for this reason that many studies have opted for list-based definitions, an approach that is supported in the East (Al-Eraky & Chandratilake, 2012; Al-Eraky et al., 2014; Pan et al., 2013).

The aim of this study was to develop a culturally appropriate conceptual framework of medical professionalism in Sri Lanka using a combination of qualitative and quantitative methods. We envisioned that identifying a list of desirable attributes would be appropriate, providing a definition that could readily be operationalised for teaching/learning, assessment and research purposes (Wilkinson, Wade, & Knock, 2009).

II. METHODS

A. The Approach

We followed a consensus approach, and opted for the Delphi technique as it was imperative to involve a large number of participants not limited by geographical location (Humphrey-Murto et al., 2017). The method offered the further advantage of providing participants with equal opportunity to express their opinions (De Villiers, De Villiers, & Kent, 2005), thereby negating the possible drawbacks of face-to-face interactions and resulting in a ‘process gain’ (Powell, 2003).

B. Participant Panel

The panel comprised nation-wide stakeholders of healthcare (Table 1), from both rural and urban regions who were presumably exposed to diverse forms of medical services and geographical variations in their distribution.

Submitted: 17 March 2020
Accepted: 3 June 2020
Published online: 5 January, TAPS 2021, 6(1), 60-69
https://doi.org/10.29060/TAPS.2021-6-1/OA2239

Frank Bate¹, Sue Fyfe², Dylan Griffiths¹, Kylie Russell¹, Chris Skinner¹, Elina Tor¹

¹University of Notre Dame Australia, Australia; ²Curtin University, Australia

Abstract

Introduction: In 2017, the School of Medicine of the University of Notre Dame Australia implemented a data-informed mentoring program as part of a more substantial shift towards programmatic assessment. Data-informed mentoring, in an educational context, can be challenging with boundaries between mentor, coach and assessor roles sometimes blurred. Mentors may be required to concurrently develop trust relationships, guide learning and development, and assess student performance. The place of data-informed mentoring within an overall assessment design can also be ambiguous. This paper is a preliminary evaluation study of the implementation of data informed mentoring at a medical school, focusing specifically on how students and staff reacted and responded to the initiative.

Methods: Action research framed and guided the conduct of the research. Mixed methods, involving qualitative and quantitative tools, were used with data collected from students through questionnaires and mentors through focus groups.

Results: Both students and mentors appreciated data-informed mentoring and indications are that it is an effective augmentation to the School’s educational program, serving as a useful step towards the implementation of programmatic assessment.

Conclusion: Although data-informed mentoring is valued by students and mentors, more work is required to: better integrate it with assessment policies and practices; stimulate students’ intrinsic motivation; improve task design and feedback processes; develop consistent learner-centred approaches to mentoring; and support data-informed mentoring with appropriate information and communications technologies. The initiative is described using an ecological model that may be useful to organisations considering data-informed mentoring.

Keywords:            Data-Informed Mentoring, Mentoring, Programmatic Assessment, E-Portfolio

Practice Highlights

• Students and mentors appreciated the introduction of data-informed mentoring.
• Assessment policies and practices should be integrated with data-informed mentoring.
• Data-informed mentoring presents curriculum challenges in task design and framing feedback.
• The student context informs the data-informed mentoring approach (learner-centred to mentor-directed).
• Data-informed mentoring requires supportive information and communications technologies.

I. INTRODUCTION

An often-cited definition of mentoring, highlights the role of experienced and empathetic others guiding students to re-examine their ideas, learning and personal and professional development (Standing Committee on Postgraduate Medical and Dental Education, 1998).

Heeneman and de Grave (2017) identify some subtle differences between traditional conceptions of mentoring and the type of mentoring that is required under programmatic assessment, which in this paper we refer to as Data-Informed Mentoring (D-IM). For example, D-IM is embedded in a curriculum in which rich data on student progress arises from student interaction with assessment tasks, informing and enhancing their progress (see Appendix). Further, in programmatic assessment, the learning portfolio is typically the setting in which the mentor-mentee relationship develops. This setting brings together institutional imperatives (e.g. assessable tasks), and personal imperatives such as evidence of competence and personal reflection. Situating mentoring in a curriculum and assessment framework impacts upon the mentoring relationship.

Meeuwissen, Stalmeijer, and Govaerts (2019) propose that a different type of mentoring is required under programmatic assessment. Mentors interpret data and feedback provided by content experts across domains of learning thus providing an evidence-base to facilitate student reflection. They might also take on a variety of roles (e.g. critical friend, coach, assessor) that could influence the mentoring relationship including the level of trust that is established with the student. These challenges suggest that conventional definitions of mentoring might not capture the essence of D-IM. Whilst the availability of rich information potentially enhances the mentoring experience and personalises learning, mentors and students are challenged to make sense and act upon this information; students might focus on issues that fall outside of the scope of the data provided (e.g. their wellbeing); mentors may also struggle to delineate boundaries between multiple roles or draw a line on where their scope of practice, as a mentor, begins and ends.

Mentoring is a social construct and as such is best considered through a holistic lens taking account of societal, institutional and personal factors (Sambunjak, 2015). The current study adopted Sambunjak’s “ecological model” (2015, p. 48) as a framework to help understand the impact of D-IM (Figure 1). Societal, institutional and personal forces are inter-related. For example, a student’s approach to D-IM might be influenced by financial circumstances resulting in the need to work part-time (societal); a medical school’s assessment policy (institutional); or a student’s learning style (personal). The model is presented as a set of cogs where the optimal educational experience is achieved if all elements work in harmony. The study uses the ecological model to help answer the central research question that guided the study: how did students and staff react and respond to D-IM?

Figure 1. An ecological framework for conceptualizing D-IM (modified from Sambunjak, 2015)

Note. *In the median test, a comparison is made between the median rating in each group to the ‘overall pooled median’ from both groups. **Values are less than or equal to the overall pooled median therefore Median Test could not be performed. ***Significant at p < 0.05 level.

Table 1. Student Perceptions of D-IM within Cohort 1 in 2017 and 2018–Median Tests for Individual Items

The only statistically significant difference noted for Cohort 1 was for the summaries of performance provided in Blackboard that were designed to underpin D-IM. The data provided in these summaries was less valued by students who engaged with D-IM in their second year.

The aggregate mean score in response to the statements on D-IM in the survey was positive in 2017 (M=4.02; SD=0.62; n=32). Mentoring continued to be well perceived by Cohort 1 as they progressed to second year in 2018 (M=3.80; SD=0.67; n=51). The slight difference in aggregate mean scores between 2017 and 2018 is not statistically significant (t=1.571; df=82, p=0.120). Table 2 compares first year students’ perceptions of D-IM.

Item	Overall Pooled Median*	Cohort 1 n=32		Cohort 2  n=47
		n> pooled median	<= pooled median	>  pooled median	<= pooled median	Median Test (chi square (χ2); df; p value)
The mentoring process was well organised	4	6	26	9	37	χ2 =0.008; df=1; p=0.928
My mentor was personally very well organised	5	0	32	0	47	n/a**
There were an appropriate number of mentoring meetings throughout the year	4	2	30	8	39	χ2 =0.998; df=1; p=0.158
My mentor was respectful	5	0	32	0	47	n/a**
My mentor listened to me	5	0	32	0	47	n/a**
My mentor asked thought-provoking questions which helped me to reflect	4	10	22	18	29	χ2 =0.413; df=1; p=0.520
My mentor added value to my learning	4	10	22	17	30	χ2 =0.205; df=1; p=0.651
My mentor helped me to set future goals that were achievable	4	9	23	17	30	χ2 =0.558; df=1; p=0.455
The summaries provided of my performance in the Blackboard Community Site were useful in helping me to reflect on my progress	3	17	16	17	30	χ2 =1.868; df=1; p=0.172

Note. *In the median test, a comparison is made between the median rating in each group to the ‘overall pooled median’ from both groups. **Values less than or equal to the overall pooled median therefore Median Test could not be performed.

Table 2. First Year Student Perceptions of D-IM –Median Tests between Cohort 1 and Cohort 2 for Individual Items

No statistically significant differences were noted between cohorts 1 and 2.

The aggregate mean score in response to the statements on D-IM in the survey was positive for Cohort 1 in 2017 (M=4.02; SD=0.62; n=32). Equally positive responses were noted in Cohort 2 in 2018 (M=3.91; SD=0.79; n=47). The difference between aggregate mean scores for first year students’ perceptions is not statistically significant (t=0.686; df=78, p=0.495).

Data from tables 1 and 2 reveals that students are highly satisfied with three aspects of mentoring: the personal organisation of the mentor along with their respectful and listening attributes. Students were also satisfied with the mentoring process, the number of mentoring meetings, the ability of the mentoring to assist in reflection and to add value to their learning, and also the propensity of the mentor to assist in action-planning. However, the summaries provided in the Blackboard environment were a source of dissatisfaction for students.

As discussed, qualitative data were collected from students through the questionnaire and staff through focus groups. The research team collated the qualitative data and confirmed that the qualitative data corroborated quantitative results with students and mentors appreciating the introduction of D-IM. For example, “Mentor sessions are important in providing support to students and…are a welcome introduction” (Yr1 Student, 2017); “Mentoring was useful to develop self-directed learning and to check where you were” (Yr2 Student, 2018); “You get to know the students, things were revealed which would not have been otherwise” (Mentor, 2017); and “Mentoring enabled me to facilitate more, listen more. Definitely a difference when you’re one-on-one with somebody” (Mentor, 2018).

In tune with the action research method adopted by the study which seeks to identify and respond to opportunities for improvement, the Research Team identified three concerns from the qualitative data: differing views of the purpose of D-IM and the role of the mentor; the provision of student feedback and information and communications technologies (ICT); and workload.

A. Differing Views of the Purpose of D-IM and the Role of Mentor

Mentors had differing conceptions of the purpose of D-IM and the role of a mentor. Some mentors perceived their primary function to be one of facilitating reflection and being encouraging whilst others were more directive, providing advice or sharing their own experiences. “I was…a sounding board to prompt their thoughts about how their progress was going. Rather than offering ways of solving problems it was more pointing where problems might lie and encouraging them to think of solutions” (Mentor, 2017); “The basic rule is to guide them… guide them properly, maybe to get them to change their study strategies and other things” (Mentor, 2017).

 B. Provision of Student Feedback and ICT

Students reported that feedback was inconsistent in timeliness and quality. Often feedback lacked guidance for improvement or was too late for it to help the student improve their learning: “More in-depth feedback on work, and returned in a timeframe that allows it to be relevant to our learning” (Yr1 Student, 2018); “Marking seemed thoughtless and halfhearted” (Yr2 Student, 2018).The use of a Blackboard Wiki to collate and present data points was also less than ideal with students finding the site difficult to navigate and use although they generally reported that it was safe and secure.

C. Workload

Students understood the role of reflection and appreciated having a mentor although there was some misunderstanding of the role of the portfolio with some students seeing it as extra work: “The amount of work required…was disproportionate” (Yr2 Student, 2018). Some students felt that the added stress and anxiety detracted from their study of medicine: “The portfolio actually detracts from spending time learning content that is essential to clinical years” (Yr2 Student, 2018). These concerns needed to be addressed by the School and are discussed in the context of changes that have and will be made to D-IM for preclinical students in the School.

IV. DISCUSSION

On the whole there was a positive response to D-IM implementation by students and staff. This response is consistent with Frei, Stamm, and Buddeberg-Fischer (2010, p. 1) who found that the “personal student-faculty relationship is important in that it helps students to feel that they are benefiting from individual advice.”

The findings of the research, however, reveal some tensions between the various elements of Sambunjak’s (2015) ecological model that link to the three areas of concern identified in the research. These tensions are shown in Figure 2.

Figure 2. The ecological framework to explore tensions in D-IM

A. Purpose and Role of Mentors and D-IM

The role of the mentor at the School is to support and guide students, and this role was not confused with other functions such as content expert or assessor. In this respect, the role conflict described by Meeuwissen et al. (2019) and Heeneman and deGrave (2017) was not evident at the School. However, mentoring approaches were situated on a continuum between learner-centred and mentor-directed. It is probable that the mentor’s style–empowering, checking or directing (Meeuwissen et al., 2019, p.605)–and their potentially different view of their role impacted on how D-IM sessions played out. Three ways of understanding the role of mentor in medical education have been identified: someone who can answer questions and give advice, someone who shares what it means to be a doctor and someone who listens and stimulates reflection (Stenfors-Hayes, Hult, & Owe Dahlgren, 2011). In a study of mentoring styles of beginning teachers, Richter et al. (2013) found that the mentor’s beliefs about learning have the greatest impact on the quality of the mentoring experience. Although professional development was provided to mentors on their role as facilitators of reflection and these issues were outlined and discussed, there were differences in interpretation of the role in the D-IM context.

Heeneman and de Grave (2017) argue that students need to be self-directed in order to be effective medical professionals. It is posited that a number of factors can influence the extent to which the mentor directs proceedings including the mentor’s experience, role clarity, rate of student progress, depth of student reflections and the perceived importance of the data required for assessment purposes.

In this study most students engaged positively with D-IM, though, albeit with variations in the extent and quality of reflection and action planning. A slight decrease in students’ enthusiasm towards D-IM was noted as they progressed from first to second year. This could be related to the novelty of D-IM diminishing over time that has been evident in other educational technology innovations (Kuykendall, Janvier, Kempton, & Brown, 2012). However, students also have a different mentor in each year. According to Sambunjak (2015), mentoring requires commitment sustained over a long period of time. At Maastricht University, for example, Heeneman and de Grave (2017) report that students are allocated the same mentor for a four-year medical course. It is, therefore, likely that in the current study the short timeframe for mentors to establish student relationships, and the introduction of a different mentor each year contributed to a reduction in student satisfaction.

B. Feedback and ICT Support

D-IM is dependent on quality data. That is, the perceived value of tasks that students engage with, and the feedback that they receive on, these tasks. Findings suggest that students found some tasks repetitive and feedback belated and superficial. Better task design and feedback practices are required. This finding is consistent with those of Bate, Macnish and Skinner (2016) in a study of task design within a learning portfolio. Findings also indicated dissatisfaction with Blackboard ICT environment. The portal was not intuitive and the structure and requirements for use of the template did not stimulate the desired level of reflection.

 C. Workload

Students at the School are “time poor” and many work part-time whilst studying. They are graduate entrants used to achieving academic success. Most are millennials comfortable with distilling and manipulating data and using online technologies. These characteristics are consistent with what Waljee, Copra, and Saint (2018) see as the new breed of medical students, being accustomed to distilling information and desirous of rapid career advancement. In these circumstances, it is unsurprising that students valued D-IM as it promoted focused data-driven discussion on their progress. However, it is also unsurprising that students were critical of anything that, in their opinion, did not support the “study of medicine”. Although students were sometimes critical of tasks that fed into D-IM (Bate et al., 2020), the reflective and action planning components of DI-M were not onerous and were at any rate optional.

For most students, grades rather than learning were paramount and this created a competitive environment which fuelled strategic learning in engaging with tasks underpinning D-IM. The School’s Assessment Policy has implications here. Progression is determined by passing discrete assessments and causes students to focus on grades rather than learning. These dispositions play out in D-IM sessions where, for example, goals are sometimes framed around passing examinations rather than addressing deficits in understanding. The School also distinguishes between formative and summative assessment with the result being that formative assessments are less valued by students. Opportunities to test understanding through formative testing are sometimes not taken up and result in less information for students and their mentor to gauge learning progress.

Bhat, Burm, Mohan, Chahine, and Goldszmidt (2018, p. 620) identified a set of “threshold concepts” in medicine that are crucial for students transitioning into clinical practice. Among these are self-directed, metacognitive and collaborative dispositions to learning. However, for a student in the preclinical years, these threshold concepts are not perceived to be the important factors that determine their progress through the course and their aim to become a doctor. Thus the tensions between students valuing mentoring but feeling that reflecting on their performance through D-IM is time-consuming and unrelated to their course progression is a source of tension within the model.

D. Actions as a Result of the Study

The action research approach of this study meant that in all results the Research Team was looking for ways to improve the system. Some issues could be improved quickly. A refinement of the Blackboard environment and a change to a software solution called SONIA was implemented in 2019 to improve the ICT interface and reduce workload. Continuing professional development (PD) for staff is undertaken and takes the research results into account. Within the mentor PD program, the Research Team saw that mentoring requires mentors to be able to diagnose the readiness and willingness of students to consider their learning educational journey. This means that, whilst the D-IM program needs a consistent view of D-IM where mentors see their role as facilitating reflection, different mentoring skills and behaviours are needed by mentors for different students. PD is also needed for students so that they understand the relationship between their achievement of learning and the role of D-IM in their journey.

Some issues are longer-term or resource dependent. A focus on the role of feedback in the system, especially for student reflection and its timeliness for mentoring sessions and action planning is critical to making D-IM valued by students. However, it is not always possible for staff to provide feedback in an optimum timeframe although the quality of the feedback can be improved by clear guidelines, expectations and an intuitive online interface.

Of great complexity and more difficult to resolve is the tension between developing the “threshold concepts” (Bhat et al., 2018); the generic skills which are built on self-reflection and are supported by D-IM and the ways in which a student progresses through the course. These are School-based rules of progression and produce a framework within which D-IM needs to operate.

V. LIMITATIONS OF THE STUDY

The study was conducted at one University and although it will ultimately cover a six-year timeframe, findings should be gauged within the context of this setting. Relatively low response rates were noted, and selection bias is a possibility with students most engaged with D-IM completing the questionnaire. Although professional development was provided to underpin the mentoring role, there was variation in the way tutors interpreted this role. The study was conducted at a time where other changes were occurring at the School (e.g. development of more continuous forms of assessment) and these changes might have impacted on D-IM. The questionnaire used in the study contained nine questions on mentoring. To gain a more nuanced understanding of D-IM at the School, it may be useful to use a comprehensive and validated questionnaire (e.g. Heeneman & de Grave, 2019) capturing the perceptions of mentees and mentors.

VI. CONCLUSION

The School aims to create quality, patient-centred and compassionate doctors who are lifelong learners (Candy, 2006). D-IM is an effective augmentation to the School’s educational program and the paper has demonstrated that it was well received by students and staff. Future directions include consideration of D-IM in clinical mentoring, development of more consistent learner-centred approaches to mentoring; improved task design and feedback; support for D-IM with appropriate ICT; and better integration of D-IM with assessment policies and practices.

Notes on Contributors

Associate Professor Frank Bate completed his PhD at Murdoch University. He is the Director of Medical and Health Professional Education at the School of Medicine Fremantle, University of Notre Dame Australia. He conceptualised and led the research, and was the primary author responsible for developing, reviewing and improving the manuscript.

Professor Sue Fyfe attained her PhD at the University of Western Australia and is an adjunct professor at Curtin University. She assisted in conceptualising the research design, conducted the qualitative data analysis and made a significant contribution to reviewing and improving the manuscript.

Dr Dylan Griffiths has a PhD from the University of Essex and is the Quality Assurance Manager at the School of Medicine Fremantle, University of Notre Dame Australia. He conducted data collection and assisted with preliminary analysis.

Associate Professor Kylie Russell obtained her PhD from the University of Notre Dame Australia. She is currently a Project Officer at the School of Medicine Fremantle, University of Notre Dame Australia. She assisted in the development of the research methodology and made a contribution to reviewing and improving the manuscript.

Associate Professor Chris Skinner completed his PhD at the University of Western Australia. He is Domain Chair of Personal and Professional development at the School of Medicine Fremantle, University of Notre Dame Australia. He assisted in conceptualising the research design and made a contribution to reviewing and improving the manuscript.

Associate Professor Elina Tor completed her PhD at Murdoch University and is the Associate Professor of Psychometrics at the School of Medicine Fremantle, University of Notre Dame Australia. She helped conceptualise the research design, led the quantitative data analysis, and made a significant contribution to reviewing and improving the manuscript.

Ethical Approval

The University of Notre Dame Australia Human Research Ethics Committee (HREC) has provided ethical approval for the research (Approval Number 017066F).

Acknowledgement

The authors acknowledge the thoughtful and insightful feedback provided by staff and students.

Funding

No internal or external funding was sought to conduct this research.

Declaration of Interest

There is no conflict of interest to declare.

References

Bate, F., Fyfe, S., Griffiths, D., Russell, K., Skinner, C., & Tor, E. (2020). Does an incremental approach to implementing programmatic assessment work: Reflections on the change process. MedEdPublish, 9(1), 55. https://doi.org/10.15694/mep.2020.000055.1

Bate, F., Macnish, J., & Skinner, C. (2016). The cart before the horse? Exploring the potential of ePortfolios in a Western Australian medical school. International Journal of ePortfolio, 6 (2), 85-94.

Bhat, C., Burm, S., Mohan, T., Chahine, S., & Goldszmidt, M. (2018). What trainees grapple with: A study of threshold concepts on the medicine ward. Medical Education, 52(6), 620–631. https://doi.org/10.1111/medu.13526

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. https://doi.org/10.1191/1478088706qp063oa

Candy, P. (2006). Promoting lifelong learning: Academic developers and the university as a learning organization. International Journal for Academic Development, 1(1), 7-18. https://doi.org/10.1080/1360144960010102

Frei, E., Stamm, M., & Buddeberg-Fischer, B. (2010). Mentoring programs for medical students: A review of PubMed literature 2000-2008, BMC Medical Education, 10(32), 1-14. https://doi.org/10.1186/1472-6920-10-32

Gillis, A., & Jackson, W. (2002). Research for Nurses: Methods and Interpretation. Philadelphia, PA: F.A. Davis Co.

Heeneman, S., & de Grave, W. (2017). Tensions in mentoring medical students toward self-directed and reflective learning in a longitudinal portfolio-based mentoring system – An activity theory analysis. Medical Teacher, 39(4), 368-376. https://doi.org/10.1080/0142159X.2017.1286308

Heeneman, S., & de Grave, W. (2019). Development and initial validation of a dual-purpose questionnaire capturing mentors’ and mentees’ perceptions and expectations of the mentoring process. BMC Medical Education, 19(133), 1-13. https://doi.org/10.1186/s12909-019-1574-2

Kemmis, S., & McTaggart, R. (2000). Participatory action research. In N. K. Denzin & Y. S. Lincoln (Eds.) Handbook of Qualitative Research (2^nd Ed.; pp 567-606). New York: Sage Publications.

Kirkpatrick, D., & Kirkpatrick, J. (2006). Evaluating Training Programs: The Four Levels (3rd ed.). Oakland, CA: Berrett-Koehler Publishers, Inc.

Kuykendall, B., Janvier, M., Kempton, I., & Brown, D. (2012). Interactive whiteboard technology: Promise and reality. In T. Bastiaens & G. Marks (Eds.), Proceedings of E-Learn 2012 – World Conference on E-Learning in Corporate, Government, Healthcare, and Higher Education 1 (pp. 685-690). Retrieved from Association for the Advancement of Computing in Education (AACE), https://www.learntechlib.org/p/41669

Meeuwissen, N., Stalmeijer, R., & Govaerts, M. (2019). Multiple-role mentoring: Mentors conceptualisations, enactments and role conflicts. Medical Education, 53, 605-615. https://doi.org/10.1111/medu.13811

Richter, D., Kunter, M., Lüdtke, O., Klusmann, U., Anders, Y., & Baumert, J. (2013). How different mentoring approaches affect beginning teachers’ development in the first years of practice. Teaching and Teacher Education, 36, 166-177. https://doi.org/10.1016/j.tate.2013.07.012

Sambunjak, D. (2015). Understanding the wider environmental influences on mentoring: Towards an ecological model of mentoring in academic medicine. Acta Medica Academia, 44(1), 47-57. https://doi.org/10.5644/ama2006-124.126

Standing Committee on Postgraduate Medical and Dental Education. (1998). Supporting Doctors and Dentists at Work: An Enquiry into Mentoring. London: SCOPME.

Stenfors-Hayes, T., Hult, H., & Owe Dahlgren, L. (2011). What does it mean to be a mentor in medical education? Medical Teacher, 33(8), 423-428. https://doi.org/10.3109/0142159X.2011.586746 

Waljee, J. F., Copra, V., & Saint, S. (2018). Mentoring Millennials. JAMA, 319(15), 1547-1548. https://doi.org/10.1001/jama.2018.3804

*Frank Bate
Medical and Health Professional Education,
School of Medicine Fremantle,
University of Notre Dame Australia,
PO Box 1225, Fremantle,
Western Australia 6959
Telephone: +66 9433 0944
Email address: frank.bate@nd.edu.au

Submitted: 20 March 2020
Accepted: 28 July 2020
Published online: 5 January, TAPS 2021, 6(1), 70-82
https://doi.org/10.29060/TAPS.2021-6-1/OA2241

Sandra Widaty¹, Hardyanto Soebono², Sunarto³ & Ova Emilia⁴

¹Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia – Dr. Cipto Mangunkusumo Hospital, Indonesia; ²Department of Dermatology and Venereology Faculty of Medicine, Universitas Gadjah Mada, Indonesia; ³Pediatric Department, Faculty of Medicine, Universitas Gadjah Mada Indonesia, Indonesia; ⁴Medical Education Department, Faculty of Medicine, Universitas Gadjah Mada, Indonesia

Abstract

Introduction: Performance assessment of residents should be achieved with evaluation procedures, informed by measured and current educational standards. The present study aimed to develop, test, and evaluate a psychometric instrument for evaluating clinical practice performance among Dermatology and Venereology (DV) residents.

Methods: This is a qualitative and quantitative study conducted from 2014 to 2016. A pilot instrument was developed by 10 expert examiners from five universities to rate four video-recorded clinical performance, previously evaluated as good and bad performance. The next step was the application of the instrument to evaluate the residents which was carried out by the faculty of DV at two Universities.

Results: The instrument comprised 11 components. There was a statistically significant difference (p < 0.001) between good and bad performance. Cronbach’s alpha documented high overall reliability (a = 0.96) and good internal consistency (a = 0.90) for each component. The new instrument correctly evaluated 95.0% of poor performance. The implementation study showed that inter-rater reliability between evaluators range from low to high (correlation coefficient r =0.79, p < 0.001).

Conclusion: The instrument is a reliable and valid instrument for assessing clinical practice performance of DV residents. More studies are required to evaluate the instrument in different situation.

Keywords:            Instrument, Clinical Assessment, Performance, Resident, Dermatology-Venereology, Workplace-Based Assessment

Practice Highlights

• The residents’ performance will reflect on their professionalism and competencies. Furthermore, clinical care provided by Dermatology and Venereology field is unique, therefore a standard instrument is needed to assess their performance.
• Dermatology – Venereology Clinical Practice Performance Examination instrument is proven to be reliable and valid in assessing residents’ clinical performance

I. INTRODUCTION

Performance assessment in medical clinical practice has been a great concern for medical education programmes worldwide. (Holmboe, 2014; Khan & Ramachandran, 2012; Naidoo, Lopes, Patterson, Mead, & MacLeod, 2017). It is an accepted premise that performance may differ according to competency (Cate, 2014; Khan & Ramachandran, 2012). Performance also occurs within a domain; therefore, the assessment of performance should be separated from that of competency. Performance assessment of medical residents should also be informed by existing medical standards and performance criteria (Li, Ding, Zhang, Liu, & Wen, 2017; Naidoo et al., 2017).

Assessment of residents during their training programme is an important issue in postgraduate medical education, which has declared formative evaluation and constructive feedback as priorities (World Federation for Medical Education, 2015). An earmark of postgraduate medical specialist training is that it occurs in the workplace; therefore, the most appropriate measurement tools are Workplace-Based Assessments (WPBA). In medical education, these assessments emphasise on result and professionalism (Boursicot et al., 2011; Joshi, Singh, & Badyal, 2017).

In response to a standardisation programme for postgraduate medical specialist training (PMST), the World Federation for Medical Education (WFME) had published guidelines which adopted by several countries including Indonesia (Indonesian College of Dermatology and Venereology, 2008; World Federation for Medical Education, 2015). Clinical care provided in the Dermatology and Venereology (DV) field is unique; a brief examination of the patient is often useful before taking a lengthy history (Garg, Levin, & Bernhard, 2012). Privacy is a top priority, especially for venereology patients, patients with communicable diseases, cosmetic dermatology and skin surgery care.

Until now, no standard instrument has been available for performance assessment of PMST in DV; therefore, a variety of assessments are in use which may cause discrepancies (Jhorar, Waldman, Bordelon, & Whitaker-Worth, 2017). A valid and reliable method of assessment is required that can be used in various facilities and related to proficiency in both content and process (Kurtz, Silverman, Benson, & Drapper, 2003). Therefore, a study was conducted to focus on the development of a residents’ clinical performance assessment based on certain standards and principles such as the WPBA and WFME standards.

II. METHODS

A. Instrument Development

The instrument was developed and tested using qualitative and quantitative study designs. It started with a solicitation of inputs regarding expected performance from a variety of stakeholders in DV: patients, nurses, laboratory staff, newly graduated DV specialists, DV practitioners, and faculty. A literature review was performed, which included various documents such as the educational programme standards for DV residents, and documentation on available assessment tools (Cate, 2014; Hejri et al., 2017; Norcini, 2010). The instrument was developed according to the current standards (Campbell, Lockyer, Laidlaw, & MacLeod, 2007; McKinley, Fraser, van der Vleuten, & Hastings, 2000).

The resulted 11-items instrument was subsequently evaluated by faculty groups from various universities in Indonesia. Repeated revisions were carried out. Psychometric data for the instrument were provided through independent evaluations of performance videos of the residents and also through comparison of the results of the new instrument (Dermatology -Venereology Clinical Practice Performance Examination/DVP-Ex) and the compared instrument. The design was a validation study in which psychometric data for the instrument were provided. Further step was the assessment of residents’ performances when performing their clinical practice using the instrument to evaluate instrument reliability and feedback. Flowchart of the study process is shown in Appendix A.

B. Setting

The present study was conducted at the Department of Dermatology and Venereology, Dr. Cipto Mangunkusumo Hospital, a teaching hospital for Faculty of Medicine Universitas Indonesia, from 2014 to 2016. The study was conducted in four steps. When developing the instrument (Step 1), we included faculty members from five medical faculties in Indonesia that have DV Residency Programme (Universitas Indonesia, Universitas Sriwijaya (UNSRI), Universitas Padjajaran (UNPAD), Universitas Gadjah Mada, and Universitas Sam Ratulangi) through in depth interview and expert panel. The study received ethical approval from the Research Ethics Committee of the Faculty of Medicine Universitas Gadjah Mada Number KE/FK/238/EC.

The instrument that had been developed was sent to five senior faculty members from three universities (Department of Dermatology and Venereology, Universitas Indonesia, UNPAD and UNSRI) (Step 2). They were asked to give their assessment in order to have face and content validity. As a test of criterion validity, we recruited 10 faculty members of Faculty of Medicine, Universitas Indonesia, randomised them into two groups. Randomisation was performed to prevent bias against the instruments being tested. One group used DVP-Ex and the other used the current instrument. The single inclusion criterion was more than three years of teaching experience. After receiving some inputs, final correction was done and training was provided for faculty member who would use the instrument.

C. Performance Video

To obtain standardised performance of the residents, video recordings of the resident’s clinical practice were made. Two residents were voluntarily recruited and a special team recorded their clinical practice performance using scenarios created by the first author. (Campbell et al., 2007; McKinley et al., 2000)

There were four videos, each of which showed the clinical practice performance of the residents when they were presented with a difficult case (dermatomyositis) and a common case (leprosy tuberculoid borderline type). Patients had to sign informed consent before included in this study. A good (first and fourth video clips) and poor (second and third clips) standard of performance were demonstrated. Activities presented in the scenarios were those associated with patient care (Campbell et al., 2007; Iobst et al., 2010). After the recording session was finished, patients were managed accordingly and provided with rewards.

D. Training on the Performance Instrument

An hour-long training was provided for the 10 faculty members (the examiners). The faculty then practiced scoring, using the recorded video clips. During the training, we received some input and made necessary corrections to the rubrics. There was no training given for the comparison instrument because the entire faculty was already accustomed to this instrument. Step 3 is the step to produce validity, reliability and accuracy of performance instrument, which was conducted through a comparative study between two instruments of assessment; i.e. performance and control instruments. It evaluated the clinical practice performance of residents in the form of video film recording their performance

 E. Implementation of Resident Performance Assessment with Performance Instrument

This step was aimed to evaluate the reliability of the instrument and results of instrument implementation when it was used to assess the residents (Step 4). The sample included residents of Postgraduate Medical Specialist Training Programme in Dermatology and Venereology, Faculty of Medicine, University of Indonesia and UGM, who were at their basic level (residents who were on their 1st semester in clinical setting), intern level (semester II-V) and independent level (semester VI or higher). 

Sample size:  n = 3 – 4/level/Faculty of Medicine = 20. The evaluators were five lecturers/ Faculty of Medicine = 10, and each lecturer evaluated six residents.

F. Data Collection

One week after the training, the instrument was evaluated. Faculty members assessed the performance of the residents in the four video recordings at the same time. Three days later, the groups underwent a rotation to reassess the video with whichever of the two instruments they had not already used. The examiners were asked to provide feedback and information on the ease of completing the instrument and the clarity of its instructions.  For the implementation of resident assessment performance with the instrument, one resident was being evaluated by three lecturers simultaneously. The lecturers were grouped randomly; therefore, every lecturer could evaluate six residents out of ten residents from each group that would be assessed.

G. Data Analysis

The analyses aimed to evaluate validity, reliability, and precision of the instrument for discriminating the performance of the residents as poor, good, or excellent.

H. Validity and Reliability

A reliability test was performed, i.e. internal consistency in the form of responses against items in each field (Cronbach alpha coefficient). Face and content validity were assessed by addressing the relevant performance standards and criteria, and by optimizing clarity of instruction, specific criteria, acceptable format, gradation of responses, correct and comprehensive answers (including all assessed variables). The cut-off score of the instrument was determined using ROC (receiver operating curve) principles, which was then used to evaluate sensitivity, specificity, positive and negative predictive value. The accuracy of the instrument was determined to evaluate the precision of the instrument in distinguishing between good and poor performance.

I. Statistical Analysis

The statistical analysis was performed using SPSS 11.5 software. Total assessment scores of each examiner were analysed using analysis of variance (ANOVA). Internal consistency was determined using Cronbach’s α and Spearman analysis was performed to acquire p value for the validity. The accuracy was determined by comparing failed or passed score results and comparing it with the video. To obtain the intergroup difference, McNemar’s test and Kappa analysis were carried out. Qualitative analysis was also performed, especially to evaluate feedbacks by performing several analytical steps.

III. RESULTS

A performance instrument was developed with 11 competency components, for which evaluation responses were given in the form of rubric scale (Appendix B). All 10 faculty members completed an assessment of each of the four videos. Eight examiners had more than 3 years of teaching experiences, and five examiners were DV consultants.

A. Validity

For validity, face, content, and construct validity remain solid points of reference for validity evaluation (Colliver, Conlee, & Verhulst, 2012; Johnson & Christensen, 2008). Face content was evaluated by five experts from three universities. The evaluation was implemented to improve the instrument. The scale of the rubrics described the capacity of residents to perform activities according to the Standard Competency of DV specialist and the domain of performance for physicians has made the instrument evaluated as the instrument with good validity on its face, content and construction.

The results of the assessments made on performance videos with the DVP-Ex showed that examiners agreed that the performances of the first and fourth videos (the “good” videos) were good performance (>60); conversely, the second and third videos (the “bad” ones) were evaluated as poor performance by 10 and 9 out of 10 faculty members, respectively (Table 1).

Note: Chi Square, Kruskal–Wallis p < 0.001

Table 1. Assessment scores for each of the four videos (n = 10)

Faculty members also gave feedback suggesting that the instrument would be useful for assessing residents’ performance. They also commented that the instrument was more objective than the one currently in use, that it was challenging in that they had to read the instrument carefully in order to use it properly, and that the response options allowed several aspects of the residents’ performance to be assessed.

B. Validity and Reliability

Validity of the instrument was measure using Spearman analyses showed significant result for all of the competency component (p > 0.001). Reliability measure of the correlation between each item score and the total score on all relevant items (Cohen, Manion, & Morrison, 2008). Our analysis revealed good overall reliability, with Cronbach α = 0.96. All components of competency achieved internal reliability scores >0.95. The correlation between each item score on the competency components and the overall score was excellent (range: 0.64–0.99).

Submitted: 16 April 2020
Accepted: 24 June 2020
Published online: 5 January, TAPS 2021, 6(1), 83-92
https://doi.org/10.29060/TAPS.2021-6-1/OA2251

Eng Koon Ong 

Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore; Assisi Hospice, Singapore

Abstract

Introduction: Physician empathy is declining due to an unproportionate focus on technical knowledge and skills. The medical humanities can counter this by allowing connection with our patients. This is a pilot study that aims to investigate the acceptability, efficacy, and feasibility of a humanities educational intervention to develop physician empathy.

Methods: Junior doctors at the Division of Supportive and Palliative Care at the National Cancer Centre Singapore between July 2018 and June 2019 attended two small-group sessions facilitated by psychologists to learn about empathy using literature and other arts-based materials. Feasibility was defined as a completion rate of at least 80% while acceptability was assessed by a 5-question Likert-scale questionnaire. Empathy was measured pre- and post-intervention using Jefferson’s Scale of Physician Empathy (JSPE) and the modified-CARE (Consultation and Relational Empathy) measure.

Results: Seventeen participants consented, and all completed the programme. Acceptability scores ranged from 18 to 50 out of 50 (mean 38, median 38). There was an increase in JSPE scores (pre-test mean 103.6, SD=11.0 and post-test mean 108.9, SD=9.9; t (17) =2.49, P=.02). The modified-CARE score increased between pre-test mean of 22.9(SD=5.8) and a post-test mean of 28.5(SD=5.9); t (17) = 5.22, P<0.001.

Conclusion: Results indicate that the programme was acceptable, effective, and feasible. The results are limited by the lack of longitudinal follow-up. Future studies that investigate the programme’s effect over time and qualitative analysis can better assess its efficacy and elicit the participants’ experiences for future implementation and refinement.

Keywords:            Empathy, Humanities, Literature, Palliative Medicine

Practice Highlights

• The medical humanities can be used to teach empathy by facilitating reflective practice.
• This novel educational programme was acceptable, effective, and feasible.
• Limitations include the lack of longitudinal follow-up and the quantitative nature of assessment.
• Future studies should investigate the programme’s effect over time and include qualitative analysis.

II. METHODS

A. Intervention Design

The Humanistic Aspirations as a Propeller of Palliative medicine Education (HAPPE) programme was conceived to introduce and develop a novel curriculum in empathy for junior doctors undergoing a palliative medicine rotation.  The overall goal of the study was to design an effective education programme based on the humanities to teach doctors empathy. Our study draws upon Schon’s work of Reflective Practice (see Table 2; Schön, 1987).

Submitted: 21 February 2020
Accepted: 13 July 2020
Published online: 5 January, TAPS 2021, 6(1), 93-108
https://doi.org/10.29060/TAPS.2021-6-1/OA2229

Kah Wei Tan¹, Hwee Kuan Ong² & Un Sam Mok³

¹Ministry of Health Holdings, Singapore; ²Department of Physiotherapy, Singapore General Hospital, Singapore; ³Division of Anaesthesiology and Peri-operative Medicine, Singapore General Hospital, Singapore

Abstract

Introduction: During resuscitations, healthcare professionals (HCPs) find balancing the need for timely resuscitation and adherence to infection prevention (IP) measures difficult. This study explored the effects of an innovative teaching method, using in-situ simulation and inter-professional education to enhance compliance to IP through better inter-professional collaboration. 

Methods: The study was conducted in the Surgical Intensive Care Unit (SICU) in a 1200-beds teaching hospital. HCPs working in the SICU were conveniently allocated to the intervention or control group based on their work roster. The intervention group attended an in-situ simulated scenario on managing cardiac arrest in an infectious patient. The control group completed the standard institution-wide infection control eLearning module. Outcomes measured were: (a) attitudes towards inter-professional teamwork [TeamSTEPPS Teamwork Attitudes Questionnaire (TAQ)], (b) infection prevention knowledge test, (c) self-evaluated confidence in dealing with infectious patients and (d) intensive care unit (ICU) audits on infection prevention compliance during actual resuscitations.

Results: 40 HCPs were recruited. 29 responded (71%) to the pre- and post-workshop questionnaires. There were no significant differences in the TeamSTEPPS TAQ and infection prevention knowledge score between the groups. However, ICU audits demonstrated a 60% improvement in IP compliance for endotracheal tube insertion and 50% improvement in parenteral medication administration. This may be attributed to the debriefing session where IP staff shared useful tips on compliance to IP measures during resuscitation and identified threats that could deter IP compliance in SICU.

Conclusion: Learning infection prevention through simulated inter-professional education (IPE) workshops may lead to increased IP compliance in clinical settings.

Keywords:            Inter-Professional Education, Simulation Infection Control, Resuscitation, Inter-Professional Teamwork

Practice Highlights

• Use of a simulated scenario to improve infection prevention during resuscitation.
• Improving attitudes towards inter-professional collaboration amongst healthcare professionals.
• Evaluating the efficacy of a simulated scenario through clinical audit.

I. INTRODUCTION

Adherence to infection prevention is paramount in the intensive care unit (ICU) as hospital acquired infections in the critically ill are associated with increased morbidity, mortality, length of stay and healthcare cost (Gandra & Ellison, 2014). However, during resuscitations, healthcare professionals (HCPs) may experience difficulty in balancing the need for resuscitation and adherence to infection prevention guidelines, resulting in suboptimal compliance to basic infection prevention measures (Steinemann et al., 2016). Moreover, resuscitation is a time-critical endeavour that requires good collaboration in a team comprising of different HCPs fulfilling different roles with different priorities, and lapses in teamwork may arise in a team comprising of HCPs with different roles and priorities (Barr, Koppel, Reeves, Hammick, & Freeth, 2009).

Inter-professional education (IPE) is defined as “occasions when two or more professions learn with, from and about each other to improve collaboration and quality of care” by the Centre for Advancement of Interprofessional Education (CAIPE) (Steinert, 2005). It is known to improve patient safety through improving communication, understanding and knowledge to encourage active participation from different HCPs (Oandasan, 2007; Wong, Lee, Allen, & Foong, 2020). Research has shown that active collaboration amongst HCPs in the workplace resulted in improved patient outcomes and provider satisfaction (Wagner, Parker, Mavis, & Smith, 2011). Previous studies had investigated the outcomes of using IPE workshops to teach infection prevention in non-emergency clinical settings or using standardised patients, and concluded that knowledge and confidence in infection prevention and inter-professional teamwork had improved (Mundell, Kennedy, Szostek, & Cook, 2013).

Currently, infection prevention education in our institute is didactic and web-based. Although this method is effective in disseminating information, there are no opportunities to learn with different HCPs or apply knowledge to real-life scenarios. On the basis that resuscitation is traditionally taught using simulation and has been proven to be highly effective (Perkins, 2007), we developed an IPE simulation workshop on infection prevention during resuscitation.

We hypothesised that the in-situ simulation workshop involving different HCPs will result in improved attitudes towards inter-professional teamwork and improved compliance to infection prevention guidelines, compared to our standard institutional infection control (IC) education.

 II. METHODS

A. Study Population

We conducted a non-randomised experimental study amongst HCPs working in the Surgical Intensive Care Unit (SICU) of the Singapore General Hospital (SGH). All HCPs working in the SICU were eligible to participate in the study. There were no exclusion criteria. Informed consent was obtained from all participating HCPs. Information on participants’ profession, the year they obtained their professional qualification, the number of years they had worked in critical care and prior experience in simulation training were collected. HCPs from Anaesthesiology, Nursing, Physiotherapy, Pharmacy, Speech and Language Therapy, Dietetics and Infection Prevention were involved.  A working day was picked to run the workshop and HCPs on duty that day were allocated to the intervention group, while those there were not on duty were assigned to the control group.

B. In-Situ Simulation Workshop

Participants in the intervention group (n=25) underwent a two-hour in-situ simulation workshop in the SICU on the scenario of a cardiac arrest in an infectious patient (Annex A). The training faculty comprised of HCPs from various professions such as Anaesthesiology, Nursing, Physiotherapy, Pharmacy, Speech and Language Therapy, Dietetics and Infection Prevention. Each workshop consisted of HCPs from five to seven different professions. The learning outcomes of the workshop were (i) to practice infection prevention precautions for transmission-based infections during resuscitations and (ii) to improve attitudes towards inter-professional teamwork during a crisis situation.

The workshop was designed based on Kolb’s experiential learning theory (Kolb & Fry, 1975), which is a four-stage learning cycle consisting of (i) concrete experience, (ii) reflective observation, (iii) abstract conceptualisation and (iv) active experimentation. Concrete experience was facilitated through in-situ simulation where participants experienced real-life constraints of resuscitating an infectious patient. Following the simulation, a debrief was held by the faculty that facilitated reflective observation and abstract conceptualisation. Learning points discussed include (i) issues faced in adhering to infection prevention guidelines in a resuscitation setting, (ii) inter-professional teamwork and (iii) threats that could deter IC compliance in SICU. The final stage, active experimentation, was facilitated through actual application of learning points surmised from the workshop, and evaluated through real-time ICU audits.

C. Evaluation of Outcomes

Evaluation of the effectiveness and impact of the workshop was done in accordance with Kirkpatrick’s evaluation framework (Kirkpatrick, 1994), which emphasised the need to go beyond the immediate reactions of participants by assessing them on four different levels, which are (i) Reaction, (ii) Learning, (iii) Behaviour and (iv) Results.  “Reaction” was evaluated through the post-workshop questionnaire and participants’ responses in the post-workshop debrief with regards to the effectiveness of simulated workshops in improving inter-professional teamwork and encouraging compliance to infection prevention guidelines. The second level, “Learning”, was evaluated by discussing learning points of the workshop in the debrief, and getting participants to note down their most important takeaways regarding infection prevention and IPE in the post-workshop questionnaire. “Behavioural changes” were assessed through a real-time observational study that assessed participants’ ability to observe proper infection prevention practices during actual resuscitations in the SICU. Results, the fourth level, were difficult to evaluate due to the small sample size that we recruited.

D. Outcomes of Study

There are two primary outcomes of this study: (i) attitudes towards inter-professional teamwork and (ii) infection prevention knowledge and practices.

Changes in attitudes towards inter-professional teamwork were assessed using the TeamSTEPPS Teamwork Attitudes Questionnaire (TAQ 1.0), based on scores in the following subcategories; Team Structure, Leadership, Situation Monitoring, Mutual Support and Communication (Appendix 1). Qualitative comments on key learning points with regards to teamwork were also collected during the debriefing sessions.

Changes in infection prevention knowledge and practice were assessed in five ways:

1. An infection prevention self-evaluation questionnaire on a 5-point Likert Scale (Appendix 2).

2. A multiple-choice quiz developed by the Institutional Infection Prevention Nurse Educators (Appendix 3A and 3B).

3. Questionnaire on effectiveness of the simulation (for participants in the intervention group only) (Appendix 4).

4. Qualitative feedback on the learning points concerning infection prevention. (Appendix 5).

5. Clinical audit data that evaluated compliance to infection prevention  guidelines during resuscitations in the SICU. Two months after the simulation workshop, the data was collected by a trained hospital-based infection prevention team based on real-time observations. The audit checklist assessed proper use of personal protective equipment (PPE), hand hygiene, administration of parenteral medications and insertion of endotracheal tube (ETT).

Statistical analysis was performed using SPSS for Mac, Version 20.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were analysed using the t-test, and categorical variables were analysed using the Fisher and Chi square test. A p-value of less than 0.05 was taken to be statistically significant.

III. RESULTS

The study recruited a total of 40 HCPs. Of the 40 clinical staff working in the SICU asked to rank their responses, 29 (71%) responded to the pre- and post-workshop TAQ, self-evaluation of infection prevention knowledge and infection prevention knowledge quiz. Healthcare professions represented included doctors (31%), nurses (34%), pharmacists (10%), physiotherapists (10%), speech and language therapists (10%) and dieticians (3%).  

The intervention and control groups were not significantly different in terms of the number of years post-graduation, years of working experience in critical care and the number of simulated training sessions they have attended, excluding basic cardiac life support (BCLS) and advanced cardiac life support (ACLS). Similarly, there were no significant differences in self-evaluation of infection prevention knowledge and infection prevention scores at baseline. However, we noted significantly higher scores in the control group in Team Structure (mean difference=2.76), Leadership (mean difference =3.8), and Communication (mean difference=2.54; Table 1).

Submitted: 2 April 2020
Accepted: 3 June 2020
Published online: 5 January, TAPS 2021, 6(1), 109-113
https://doi.org/10.29060/TAPS.2021-6-1/SC2243

Wen Hao Chen¹, Shairah Radzi¹, Li Qi Chiu², Wai Yee Yeong³, Sreenivasulu Reddy Mogali¹

¹Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; ²Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore; ³Singapore Centre for 3D Printing, School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore

Abstract

Introduction: Simulation-based training has become a popular tool for chest tube training, but existing training modalities face inherent limitations. Cadaveric and animal models are limited by access and cost, while commercial models are often too costly for widespread use. Hence, medical educators seek a new modality for simulation-based instruction. 3D printing has seen growing applications in medicine, owing to its advantages in recreating anatomical detail using readily available medical images.

Methods: Anonymised computer tomography data of a patient’s thorax was processed using modelling software to create a printable model. Compared to a previous study, 3D printing was applied extensively to this task trainer. A mixture of fused deposition modelling and material jetting technology allowed us to introduce superior haptics while keeping costs low. Given material limitations, the chest wall thickness was reduced to preserve the ease of incision and dissection.

Results: The complete thoracostomy task trainer costs approximately SGD$130 (or USD$97), which is significantly cheaper compared to the average commercial task trainer. It requires approximately 118 hours of print time. The complete task trainer simulates the consistencies of ribs, intercostal muscles and skin.

Conclusion: By utilising multiple 3D printing technologies, this paper aims to outline an improved methodology to produce a 3D printed chest tube simulator. An accurate evaluation can only be carried out after we improve on the anatomical fidelity of this prototype. A 3D printed task trainer has great potential to provide sustainable simulation-based education in the future.

Keywords:            Medical Education, Chest Tube, Thoracostomy, Simulation, 3D Printing

I. INTRODUCTION

Training opportunities in procedures such as chest tube insertions are increasingly limited amidst a growing population of trainees. Yet, the deliberate practice remains essential to improving proficiency and preventing possible complications such as lung parenchymal damage (Hernandez, El Khatib, Prokop, Zielinski, & Aho, 2018). Hence, many institutions have adopted simulation-based training to provide realistic training opportunities while mitigating harm to patients.

Cadaveric and animal models are limited by access and cost, and raise religious and ethical concerns (Kovacs, Levitan, & Sandeski, 2018). In addition, commercial models tend to be very costly (e.g. Trauma-Man® at USD~$25,000). As such, new modalities are desired.

Three-dimensional (3D) printing can accurately recreate anatomical details from imaging data through precision modelling and a wide range of compatible printing materials (Mogali et al., 2018). Together with its decreasing cost, it has become an attractive technology for creating inexpensive and anatomically accurate simulation modalities.

A previous study from the Federal University of Parana, Brazil (Bettega et al., 2019) outlined the development and evaluation of a low-cost chest tube simulator. The bony structures were 3D printed, while the remainder of the model was manually assembled using silicone sheets, foam pads, and balloons.

They compared 2 groups of participants using a porcine rib model, and their 3D printed simulator respectively. They found subjective improvements in confidence and safety amongst both groups and showed no difference between the objective grades. Hence, they concluded that their 3D printed simulator was equivalent to the animal model concerning the simulation of a chest tube placement.

However, there exist many other 3D printing technologies and materials, which can potentially be applied to create superior haptics and anatomical detail. Hence, this paper aims to outline a methodology of integrating multiple 3D printing modalities to create a cost-efficient 3D printed chest tube simulator.

II. METHODS

An anonymised computerized tomography (CT) file of a healthy human thorax (2.5 mm slices thickness) in Digital Communication in Medicine (DICOM) format was downloaded from the databank provided by 3D Slicer (https://www.slicer.org/, Version 4.10.2). The CT data was available freely for research and educational use at the time of this study.

3D Slicer was employed to segment the thoracic bony structures using a radiodensity based threshold algorithm, which traces the bone based on the Hounsfield units. Due to a lack of contrast possibly from the poor resolution of the CT images, we were not able to segment the respective soft tissue layers using thresholding. Hence, the intercostal muscles were manually drawn with the paintbrush function. Intrathoracic organs were all removed to create a central cavity. From initial experimentation, we found that incision and dissection were too difficult to perform if the task trainer was printed at the true thoracic thickness. Hence, a decision was made to thin out the chest wall. At the 4^th and 5^th intercostal space midaxillary line, the mean chest wall thickness is 39mm (Laan et al., 2016), but our model measured at 18mm at this corresponding anatomical landmark.

Further processing was done to smoothen the contours of the model (see Appendix, A). Subsequently, the anatomical structures were saved as stereolithography (STL) file and exported into Materialise Magics (Version 20 by Materialise, Belgium).

On Magics, cut and Boolean techniques were used to create the replaceable component. This space was demarcated by the 5th to 6th intercostal space, between anterior axillary to the mid axillary line. To create a secure fit for the replaceable piece, a groove was created and reinforced using the cut and punch function which generates teething to maximise friction. The main frame measured 23cm (length) x 19.5cm (width) x 23.5cm (height), while the replaceable part measured 9cm (length x 8.1cm (width) x 0.8cm (height). The Fix Wizard and Shrink Wrap Part functions were used to repair the surface mesh and eliminate holes and loose shells. The models were then exported using IdeaMaker® (Raise3D, USA) and uploaded to the printer.

The model was printed in two parts: the main frame was printed using fusion deposition modelling (FDM). This technology extrudes a continuous filament of melted thermoplastic, repeated by layer based on the design coordinates. Bones were printed with polylactic acid (PLA) which is a rigid material while the intercostal muscles were printed with thermoplastic urethane (TPU) which is a flexible material. Support was printed using PLA. We utilised a dual nozzle extrusion printer (Raise3D Pro 2, Raise3D, USA) to allow us to print the bony and soft tissue simultaneously, thereby increasing convenience. The following settings were used: printing speeds were reduced to 25mm/s, retraction of the TPU extrusion head was disabled, nozzle temperatures were set at 200°C, and build plate temperature was at 65°C. Post-print processing was done to remove the support, with subsequent filing and sanding.

The replaceable part was printed using Objet500 Connex 3 (Stratasys Ltd, Eden Prairie, MN), a multi-material printer utilising material jetting technology. This technology drops liquid photopolymers onto the build tray and simultaneously cures the material using UV light. As such, we can mix plastic and rubber to create hybrid consistencies (Mogali et al., 2018) of varying shore hardness. Two materials were selected to achieve the desired haptics: VeroWhite (FullCure, RGD835) was the stiff plastic photopolymer used for bones, while Tango Plus (FullCure, 930) was the rubber photopolymer used for simulating soft tissue. Support resin (FullCure, 706) was also used for printing. Post-printing processing was required to remove the support resin.

Skin coloured silicone sheets of 5 mm thickness were wrapped around the model using generic superglue. The task trainer was cable tied to stainless steel supports and screwed onto a laminated wood baseplate. Cut sponges were wrapped in duct tape to simulate the lung parenchyma and placed into the central cavity created.

III. RESULTS

The completed task trainer is shown in Figure 1. Both the main frame and replaceable piece provided simulation for the ribs, intercostal muscles, and skin.

The 3D thoracostomy task trainer costs approximately SGD$130 (or USD$97) (excluding manpower and printer cost)–see Appendix, B). The baseplate and mount were repurposed and did not add to costs.

Note. A = completed hemithorax main frame using FDM printing; B= replaceable piece; C = task trainer without the replaceable piece. Figure 1. Photos of the completed task trainer

The main frame required 676g of polylactic acid and 114g of thermoplastic urethane. The replaceable piece required 30g of VeroWhite, 22g of Tango Plus, and 66g of Support706. It took a total of approximately 118 hours to print the entire task trainer.

 IV. DISCUSSION

Our methodology addressed several issues with the model as outlined by the Brazilian team (Bettega et al., 2019). The proposed methodology here required less manual assembly of components, thereby saving time and improving fabrication. By utilising dual extrusion printing, construction was simplified while integrating an additional material for varying consistencies. The creation of a replaceable piece also meant long term savings in the cost of utilising this model. These logistical advantages would make it easier to adopt our proposed task trainer.

Secondly, simple materials such as foam pads and silicone sheets were inferior in simulating human tissue. Our utilisation of material jetting technology with the Objet500 Connex 3 (Stratasys Ltd, Eden Prairie, MN) printer allowed us to blend plastic and rubber materials to better recreate the consistency of human tissue. This technology and blend of materials have been extensively validated in other simulation models (Mogali et al., 2018).

Cost remains an important impedance to the widespread use of simulation in procedural education. We performed a surface comparison of our product against an existing commercial model in use by a local hospital in Singapore (LF03770U by Lifeform, NASCO, USA). The task trainer outlined here (~USD$97) is significantly cheaper than the commercial trainer (~USD$1,800). Also, our material blend provides superior haptics and bony structures in the replaceable component, as compared to a plain silicone insert in the Lifeform model. These should provide improvements in the quality and quantity of simulation opportunities for training physicians.

Unfortunately, we were not able to recreate the anatomical thickness of the thorax given our material limitations at the time of writing. This inaccurate depth of dissection creates a confounding variable when evaluating our task trainer against existing cadaveric or commercial simulators. Hence, an evaluation of this task trainer was withheld to address this limitation in our future prototype. Moving forward, we plan to invite physicians to validate the efficacy of our improved task trainer.

V. CONCLUSION

We have outlined the methodology for creating a 3D printed tube thoracostomy task trainer using a combination of printing technologies. The outlined task trainer could potentially provide superior haptics at a lower cost while improving fabrication. However, an equitable validation against an existing modality of simulation can only be done after we achieve a comparable anatomical fidelity.

In our continued search for sustainable simulation models, 3D printing shows great potential in reproducing anatomical detail with superior cost efficiency. The growing availability of 3D printing infrastructure makes the large-scale adoption of such task trainers ever more realistic. It makes it therefore worthwhile to invest in the creation of the perfect 3D printed task trainer. 

Notes on Contributors

Mr. Wen Hao Chen is an undergraduate medical student with the Lee Kong Chian School of Medicine, Singapore. He was involved in the development of the task trainer, along with co-authoring the submitted manuscript.

Dr. Shairah Radzi is a research fellow with the Lee Kong Chian School of Medicine, Singapore. She was involved in the development of the task trainer, along with co-authoring the submitted manuscript.

Dr. Li Qi Chiu is a consultant physician in the Department of Emergency Medicine in Tan Tock Seng Hospital, Singapore. She was involved in the development of the task trainer, along with co-authoring the submitted manuscript.

Assoc. Prof Wai Yee Yeong is the Associate Chair (Students) of the School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore. She was involved in the development of the task trainer, providing her technical expertise on the 3D printing process, along with co-authoring the submitted manuscript.

Asst. Prof Sreenivasulu Reddy Mogali is the Head of Anatomy and Principal Investigator in Clinical Anatomy and Medical Education at Lee Kong Chian School of Medicine, Singapore. He was involved in the development of the task trainer, along with co-authoring the submitted manuscript. He serves as the principal investigator.

Ethical Approval

Approved by Nanyang Technological University’s Institutional Review Board (2019-07-017). The CT scans used were anonymised and provided free for education and research use by 3D Slicer (https://www.slicer.org/, Version 4.10.2).

Acknowledgement

The authors thank the staff and faculty of the Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore for supporting this research; Singapore Centre for 3D Printing, Nanyang Technological University for their technical support.

Funding

This project was funded by the Ministry of Education Research Start-Up Grant, Lee Kong Chian School of Medicine, Nanyang Technological University Singapore.

Declaration of Interest

All authors declare no conflict of interest. The authors alone are responsible for the content and writing of the article.

References

Bettega, A. L., Brunello, L. F. S., Nazar, G. A., De-Luca, G. Y. E., Sarquis, L. M., Wiederkehr, H. de A., … Pimentel, S. K. (2019). Chest tube simulator: Development of low-cost model for training of physicians and medical students. Revista Do Colégio Brasileiro de Cirurgiões, 46(1). https://doi.org/10.1590/0100-6991e-20192011

Hernandez, M. C., El Khatib, M., Prokop, L., Zielinski, M. D., & Aho, J. M. (2018). Complications in Tube Thoracostomy: Systematic review and Meta-analysis. The Journal of Trauma and Acute Care Surgery, 85(2), 410–416. https://doi.org/10.1097/TA.0000000000001840

Kovacs, G., Levitan, R., & Sandeski, R. (2018). Clinical Cadavers as a Simulation Resource for Procedural Learning. AEM Education and Training, 2(3), 239–247. https://doi.org/10.1002/aet2.10103

Laan, D. V., Vu, T. D. N., Thiels, C. A., Pandian, T. K., Schiller, H. J., Murad, M. H., & Aho, J. M. (2016). Chest Wall Thickness and Decompression Failure: A Systematic Review and Meta-analysis Comparing Anatomic Locations in Needle Thoracostomy. Injury, 47(4), 797–804. https://doi.org/10.1016/j.injury.2015.11.045

Mogali, S. R., Yeong, W. Y., Tan, H. K. J., Tan, G. J. S., Abrahams, P. H., Zary, N., … Ferenczi, M. A. (2018). Evaluation by medical students of the educational value of multi-material and multi-colored three-dimensional printed models of the upper limb for anatomical education. Anatomical Sciences Education, 11(1), 54–64. https://doi.org/10.1002/ase.1703

*Sreenivasulu Reddy Mogali
11 Mandalay Road, Singapore 308232
Lee Kong Chian School of Medicine,
Nanyang Technological University
Email: sreenivasulu.reddy@ntu.edu.sg

Submitted: 17 April 2020
Accepted: 05 August 2020
Published online: 5 January, TAPS 2021, 6(1), 114-118
https://doi.org/10.29060/TAPS.2021-6-1/SC2358

Warren Fong^1,3,4, Yu Heng Kwan², Sungwon Yoon², Jie Kie Phang¹, Julian Thumboo^1,2,4 & Swee Cheng Ng¹

¹Department of Rheumatology and Immunology, Singapore General Hospital, Singapore; ²Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore; ³Duke-NUS Medical School, Singapore; ⁴Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Abstract

Introduction: This study aimed to examine the perception of faculty on the relevance, feasibility and comprehensiveness of the Professionalism Mini Evaluation Exercise (P-MEX) in the assessment of medical professionalism in residency programmes in an Asian postgraduate training centre.

Methods: Cross-sectional survey data was collected from faculty in 33 residency programmes. Items were deemed to be relevant to assessment of medical professionalism when at least 80% of the faculty gave a rating of ≥8 on a 0-10 numerical rating scale (0 representing not relevant, 10 representing very relevant). Feedback regarding the feasibility and comprehensiveness of the P-MEX assessment was also collected from the faculty through open-ended questions.

Results: In total, 555 faculty from 33 residency programmes participated in the survey. Of the 21 items in the P-MEX, 17 items were deemed to be relevant. For the remaining four items ‘maintained appropriate appearance’, ‘extended his/herself to meet patient needs’, ‘solicited feedback’, and ‘advocated on behalf of a patient’, the percentage of faculty who gave a rating of ≥8 was 78%, 75%, 74%, and 69% respectively. Of the 333 respondents to the open-ended question on feasibility, 34% (n=113) felt that there were too many questions in the P-MEX. Faculty also reported that assessments about ‘collegiality’ and ‘communication with empathy’ were missing in the current P-MEX.

Conclusion: The P-MEX is relevant and feasible for assessment of medical professionalism. There may be a need for greater emphasis on the assessment of collegiality and empathetic communication in the P-MEX.

Keywords:            Professionalism, Singapore, Survey, Assessment

I. INTRODUCTION

Medical professionalism is one of the core Accreditation Council for Graduate Medical Education competencies and forms the basis of medicine’s contract with society. Unprofessional behaviour during training of junior doctors has been shown to result in future unprofessional behaviour. Assessment of professionalism not only allows for timely feedback to residents to help them improve, but also allows for development of better curriculum to prevent lapses in medical professionalism. The Professionalism Mini-Evaluation Exercise (P-MEX) had previously been identified as a potential observer-based assessment tool (Kwan et al., 2018), but it has not been validated in a multi-ethnic and multi-cultural Asian context such as Singapore. According to International Ottawa Conference Working Group on the Assessment of Professionalism, professionalism varies across cultural contexts, and therefore cross-cultural validation of the assessment tool for medical professionalism is imperative (Hodges et al., 2011). The current assessment tools adopted in local institutions may not cover the entire continuum of medical professionalism. For example, in the Ministry of Health Holdings (MOHH) C1 form which is currently being used for the assessment of residents on a 6-monthly basis, the assessment of professionalism is summative and consists of only three items (1) Accepts responsibility and follows through on tasks, (2) Responds to patient’s unique characteristics and needs equitably, (3) Demonstrates integrity and ethical behaviour.

We aimed to (1) examine faculty perception of the relevance of the P-MEX for assessment of medical professionalism in the local context, and (2) determine the feasibility and comprehensiveness of the P-MEX as an assessment tool for medical professionalism in Singapore.

II. METHODS

A. Design and Participants

We invited faculty in the SingHealth residency programmes to participate in the study by completing an online anonymous questionnaire in July 2018 to August 2018. Participants were given one week to complete the survey, with three reminder emails sent at one-week, two-weeks and one-month after the deadline for submission. SingHealth Centralised Institutional Review Board approved the conduct of this study (Reference Number: 2016/3009). Implied informed consent was provided by participants before completing the online anonymous questionnaire.

 B. Survey Questionnaire

The P-MEX consists of four domains (Doctor-patient relationship skills, Reflective skills, Time management and Inter-professional relationship skills) and 21 sub-domains. Faculty were asked to rate the relevance of each item in P-MEX using a 0-10 numerical rating scale (0 representing not relevant, 10 representing very relevant). The faculty were also asked the following open-ended questions to determine the feasibility and comprehensiveness of the P-MEX- (1) “In your opinion, is a P-MEX form with 21 items too long, making it not feasible for routine use? If so, which items should be removed?” and (2) “In your opinion, are there any missing items (observable actions of a medical professional) that should be included in this form? If so, what new items should be added?” The questionnaire also included additional questions related to demographic characteristics (age, gender, specialty and number of years since becoming a specialist).

 C. Analysis

Items were deemed to be relevant to the assessment of medical professionalism when at least 80% of the faculty gave a rating of ≥8. This was determined by expert judgement and prior literature (Avouac et al., 2011). For the open-ended questions on feasibility and comprehensiveness, responses were categorised and the number of the respondents who deemed the 21-item P-MEX to be not feasible (too long) or not comprehensive (there were missing items that should be included) are presented.

 III. RESULTS

In total, 555 faculty from 33 residency programmes participated in the survey (response rate 44%). The respondents were 59% male, median age 43 years old, age ranged from 30 to 78 years old. Specialists from medical and surgical disciplines made up 39% and 27% of the respondents respectively, with the remaining respondents coming from diagnostic radiology/nuclear medicine, anaesthesiology, paediatrics and emergency medicine (12%, 11%, 6% and 5% of the respondents respectively).

 A. Relevance

Of the 21 items in P-MEX, 17 items were deemed to be relevant (at least 80% of the faculty gave a rating of ≥8). For the remaining four items ‘maintained appropriate appearance’, ‘extended his/herself to meet patient needs’, ‘solicited feedback’, and ‘advocated on behalf of a patient’, the percentage of faculty who gave a rating of ≥8 was 78%, 75%, 74%, and 69% respectively (Figure 1). 

Figure 1: Percentage of faculty (n=555) who rated the item ≥8 on the relevance of the item in assessment of medical professionalism using a 0-10 numerical rating scale (0 representing not relevant, 10 representing very relevant).

B. Feasibility

There were 333 respondents for the question “In your opinion, is a P-MEX form with 21 items too long, making it not feasible for routine use? If so, which items should be removed?”, of which 34% (n=113) felt that there were too many questions in the P-MEX assessment form. The top four items chosen to be removed were “solicited feedback” (n=36), “extended his/herself to meet patient needs” (n=27), “advocated on behalf of a patient” (n=25), and “maintained appropriate appearance” (n=23).  208 (62%) respondents felt that the number of questions in the P-MEX assessment form was appropriate.

C. Comprehensiveness

There were 307 respondents to the question “In your opinion, are there any missing items (observable actions of a medical professional) that should be included in this form? If so, what new items should be added?”, of which 28% (n=85) faculty felt that there were missing items. The most frequently mentioned missing items were regarding assessment of ‘collegiality’ (n=54) and assessment of ‘communication with empathy’ (n=12).

Examples of ‘collegiality’ provided by faculty— “Collaboration with other healthcare professionals in the patients’ best interest”, “Demonstration of collaborative behaviour”

Examples of ‘communication with empathy ‘provided by faculty— “Communicate with empathy and effectively to patient and family, taking into account their level of understanding, education and socioeconomic background”, “Communication skills…should embrace empathy, listening skills, discretion, sensitivity and intelligence… sufficient information, counselling, planning and advice regarding medical condition and options.”

207 respondents (67%) felt that the P-MEX was comprehensive for the assessment of medical professionalism.

IV. DISCUSSION

This study provides preliminary evidence on the relevance, feasibility and comprehensiveness of the P-MEX in the assessment of medical professionalism in an Asian city state. The current study is part of a larger project to culturally adapt and validate the P-MEX. Based on our knowledge, this is the first study to explore the faculty perception on relevance, feasibility and comprehensiveness of the P-MEX in the assessment of medical professionalism in a multi-cultural and multi-ethnic context.

There were four items that were deemed to be less relevant (extended his/herself to meet patient needs, advocated on behalf of a patient, solicited feedback, maintained appropriate appearance). These findings were also similar in a validation study performed in Canada, where the items ‘extended his/herself to meet patient needs’ and ‘advocated on behalf of a patient’ were also frequently marked as ‘not applicable’, suggesting that the two items may be less relevant (Cruess, McIlroy, Cruess, Ginsburg, & Steinert, 2006). Qualitative methods can be used to explore the reasons why these items were deemed to be less relevant. About one-third of faculty felt that P-MEX was too long. Further study is warranted to evaluate the possibilities for shortening the P-MEX to reduce response burden and enhance routine use of the P-MEX.

In addition, our study revealed a need for greater emphasis on the assessment of collegiality. Some faculty felt that ‘collegiality’ was missing in the P-MEX despite the presence of items such as ‘demonstrated respect for colleagues’ and ‘avoided derogatory language’. This suggests that collegiality may encompass actions other than demonstrating respect and avoiding derogatory language in the local context, and further reinforces the emphasis of interprofessional collaborative practice. 

Faculty also felt that there was also a lack of assessment of ‘communication with empathy’ in the P-MEX. The importance of empathetic communication is also supported by a study in Indonesia, a country in the same region, which found that patients considered communication as the most important attribute of medical professionalism (Sari, Prabandari, & Claramita, 2016).

This study has some limitations. The non-response rate raises concern about possible selection bias. Non-responders may have been less enthusiastic about the assessment of medical professionalism. Medical professionalism is affected by socio-cultural factors, therefore the findings from this study may not be entirely generalizable to another socio-cultural context. In addition, we were unable to elucidate the reasons for disagreement with the relevance of some of the items in the P-MEX as many faculty did not provide feedback and comments. Nevertheless, the findings of this study can serve as basis for future research, especially in countries with similar multicultural backgrounds.

V. CONCLUSION

Faculty agreed that most of the items in the P-MEX were relevant in the assessment of medical professionalism. Majority of the faculty also felt that the P-MEX was feasible to be used routinely in the assessment in medical professionalism. There may be a need for greater emphasis on the assessment of collegiality and communication with empathy in the modified P-MEX.

Notes on Contributors

Warren Fong reviewed the literature, designed the study, collected data, analysed data, and wrote manuscript. Yu Heng Kwan reviewed the literature, designed the study, collected data, analysed data, and wrote manuscript. Sungwon Yoon advised the design of study, analysed data, and gave critical feedback to the writing of manuscript. Jie Kie Phang collected data, analysed data, and wrote manuscript. Julian Thumboo advised the design of study, and gave critical feedback to the writing of manuscript. Swee Cheng Ng advised the design of study, collected data, analysed data, and gave critical feedback to the writing of manuscript. All authors have read and approved the final manuscript.

Ethical Approval

Ethical approval for this was granted by the SingHealth Institutional Review Board (Reference Number: 2016/3009).

Acknowledgement

The authors wish to thank all the study participants for contributing to this work.

Funding

This research was supported by SingHealth Duke-NUS Medicine Academic Clinical Programme Education Support Programme Grant (Reference Number: 03/FY2017/P2/03-A47). Funder was not involved in the design, delivery or submission of the research.

Declaration of Interest

The authors declare that they have no competing interests.

References

Avouac, J., Fransen, J., Walker, U., Riccieri, V., Smith, V., Muller, C., … Matucci-Cerinic, M. (2011). Preliminary criteria for the very early diagnosis of systemic sclerosis: Results of a Delphi Consensus Study from EULAR Scleroderma Trials and Research Group. Annals of the Rheumatic Diseases, 70(3), 476-481. doi:10.1136/ard.2010.136929

Cruess, R., McIlroy, J. H., Cruess, S., Ginsburg, S., & Steinert, Y. (2006). The professionalism mini-evaluation exercise: A preliminary investigation. Academic Medicine, 81(10), S74-S78.

Hodges, B. D., Ginsburg, S., Cruess, R., Cruess, S., Delport, R., Hafferty, F., . . . Ohbu, S. (2011). Assessment of professionalism: Recommendations from the Ottawa 2010 Conference. Medical Teacher, 33(5), 354-363.

Kwan, Y. H., Png, K., Phang, J. K., Leung, Y. Y., Goh, H., Seah, Y., . . . Lie, D. (2018). A systematic review of the quality and utility of observer-based instruments for assessing medical professionalism. Journal of Graduate Medical Education, 10(6), 629-638.

Sari, M. I., Prabandari, Y. S., & Claramita, M. (2016). Physicians’ professionalism at primary care facilities from patients’ perspective: The importance of doctors’ communication skills. Journal of Family Medicine and Primary Care, 5(1), 56-60. https://doi.org/10.4103/2249-4863.184624

*Warren Fong
SingHealth Rheumatology,
Senior Residency Programme,
20 College Road,
Singapore 169856
Tel: +6563214028
Email: warren.fong.w.s@singhealth.com.sg

 

Submitted: 16 April 2020
Accepted: 21 July 2020
Published online: 5 January, TAPS 2021, 6(1), 119-121
https://doi.org/10.29060/TAPS.2021-6-1/PV2250

Annushkha Sharanya Sinnathamby

Department of Paediatrics, Khoo Teck Puat National University Children’s Medical Institute, National University Hospital, Singapore

I. INTRODUCTION

“To have striven, to have made the effort, to have been true to certain ideals – this alone is worth the struggle.”

William Osler

The word “values” is heard frequently in healthcare. From the moment we step into medical school, we are challenged to reflect what our intrinsic values are, or how we can “add value” to a department during the residency application.

With time, and in going through the system, our definitions of the word “values” may change. To me, values are those things which are right and wrong, and which are important in life. In other words, values include not only what is important to my profession and to being a good doctor, but also to what is important to being a good person.

The philosopher Alasdair MacIntyre argues that one should reflect on the following three questions at the heart of moral thinking (Hinchman, 1989):

• Who am I?
• Who ought I to become?
• How ought I to get there?

In the context of understanding our values in healthcare, I wondered if the above can be translated into:

• What are my values?
• Which values should we value?
• How should we value those values?

In this article, I aim to touch on some of my view on values in the healthcare system, from the perspective of a junior doctor.

II. ARE OUR VALUES MISPLACED?

How often do we really ask ourselves what is important, what is good, or what is morally correct?

I asked a few junior doctors what values they think are important to being a good doctor. For some, the first response was classical, including “perseverance”, “compassion”, and “integrity”. However, the first thought of many others was not to be a kind or compassionate doctor, but an efficient or skilful one. I quote some of them verbatim:

“If my seniors don’t have to do anything, because I’ve done it all, then I’ve done my job.”

“No matter how much we value empathy and respect… I feel this doesn’t matter unless you have the competency to treat your patients.”

These doctors are far from unkind, dishonest, or cold. In fact, I know them personally to be some of the most good-hearted residents at work. Despite this, “typical” values such as kindness or integrity are not values which they instinctively identify with.

It is important to distinguish that being a “good” doctor may have more than one definition. “Good” as an adjective can mean being skilled and competent; on the other hand, it also means being morally upright, kind, and compassionate. Of course, it should be no argument that every doctor should be all of the above. Yet, I fear that we may be so increasingly fixated on the former, that we begin to lose sight of the latter.

As a case in point, I challenged some of our contemporaries to see how strongly they held on to an arguably core value—integrity. This value is often tested in a common daily scenario for our junior doctors: bargaining for a scan from our Radiology colleagues, where questionable tactics are sometimes employed to ensure a slot.

I asked every junior doctor working in the department two simple questions:

1) If they had ever lied to get a scan

2) If they had ever augmented the truth to get a scan

I had assumed that not a single doctor would have outright lied to get a scan, but 7.1% admitted to having done so. Furthermore, 67.9% said they would augment the truth to get a scan. This implies that there is a spectrum from an exaggeration to an outright falsehood.

When asked to elaborate on the above question, many retrospectively regretted embellishing the truth. A senior medical officer described in detail his experience lying for a particular peripherally inserted central catheter as a house officer. Even after 4 years, he could cite shame at lying to a radiologist who could almost certainly see through the lie, and perhaps depriving another patient who needed the scan more of a slot.

Ultimately, I think this boils down to our personal yardstick of our own integrity, and how willing each of us is to allow ends to justify means. Though the change of phrasing in the question I asked led to a big change in statistics, this does not change the fact that for some doctors, “augmenting the truth” strays dangerously far from what the truth really is. 

Perhaps, it is then relevant to examine what would make a junior doctor re-order their priorities, and inadvertently compromise their own core values. In an increasingly busy environment, one reason we may lose sight of our core values is burnout. Studies in Singapore have described that between 55.1%-80.7% of residents reported burnout in some form, higher than their US counterparts (Lee, Loh, Sng, Tung, & Yeo, 2018; See et al., 2016). Furthermore, it was postulated that there was a negative correlation between burnout and empathy levels, and that overnight calls and low degrees of respect from colleagues were associated with increased stress levels. Burnout and emotional fatigue may cause us to erroneously weigh our values, and this could be why some junior doctors prioritise efficiency, meticulousness, or even keeping their seniors happy, to the extent of losing sight of their core values.

III. WHAT VALUES SHOULD WE VALUE?

It is no secret that a career in medicine is highly competitive. At every stage of training, medical student’s face a barrage of rigorous series of assessments that continue on into their professional careers. Therefore, it is important to examine the criteria we use to measure our doctors. Grading systems increasingly put emphasis on the softer side of medicine such as compassion and integrity, but more can be done to help our doctors value themselves and their own values more.

I recently filled up a typical grading form for my house officer. For 22 questions about his daily work, there was only one about his values and professionalism. It was a shame, as I strongly believe that an emphasis on our values should be a learning outcome, even if it is not a graded criterion. I was once taught that a patient may never remember your management, but will always remember your kindness—words that resonate with me even today.

On an institutional level, it is also important to have an emphasis on values. The institution I work in advocates the TRICEPS core values, a catchy acronym for Teamwork, Respect, Integrity, Compassion, Excellence, and Patient-Centeredness. While these values were probably established as a guideline to attract like-minded individuals to the institution, I also think these are a good set of values to emulate.

IV. HOW SHOULD WE VALUE OUR VALUES?

A system is only as great as its people. It is difficult to change a huge system, but it is easy to start the change from within ourselves, and those around us. It is also beneficial to ensure junior doctors are mindful of their values. In our daily practice, this means empowering them to self-reflect.

A simple way I do this is to ensure that after every night call, I debrief each member of my on-call team to highlight things I noticed they did well. I try not to focus solely on their medical decisions, but also the small things: staying beyond hours just to let a teenage patient with a chronic condition sleep in before blood taking, sitting with an anxious parent, or sacrificing rest time to offer moral support to a colleague doing a difficult procedure. My hope in doing this is to allow junior doctors to recognise good traits in themselves, so that they can further nurture them along their journey of medicine, and in turn inspire the people around them.

My second suggestion is for each of us to take a minute to remember what values brought us into medicine in the first place. For me, when I am at my most fatigued, feel most apathetic, or when something had gone wrong at work, I read the personal statement I wrote for my medical school application more than 10 years ago, and try to remember that inside me, my core values are still the same as the overly enthusiastic teenager who wrote them—though perhaps more mature, and hopefully slightly wiser too.

After all, it is only if we are certain of what we value, that we can inspire and encourage those around us to value their values too.

Note on Contributor

Annushkha is a Paediatrics Senior Resident. She has an interest in medical education, and is currently in the National University Health System’s Medical Education Residency Programme. She conceptualised and gathered information and drafted the initial manuscript, critically reviewed the manuscript for important intellectual content and revised the manuscript.

Acknowledgements

The author would like to thank A/Prof Marion Aw and A/Prof Quah Thuan Chong for providing her with inspiration and guidance in writing this article.

Funding

There was no funding involved in writing this article.

Declaration of Interest

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

References

Hinchman, L. P. (1989). Virtue or Autonomy: Alasdair MacIntyre’s Critique of Liberal Individualism. Polity, 21(4), 635-654.

Lee, P. T.,Loh, J., Sng, G., Tung, J., & Yeo, K. K. (2018). Empathy and burnout: A study on residents from a Singapore institution. Singapore Medical Journal, 59(1), 50-54.

See, K. C., Lim, T. K., Kua, E. H., Phua, J., Chua, G. S., & Ho, K. Y. (2016). Stress and burnout among physicians: Prevalence and risk factors in a Singaporean internal medicine programme. Annals, Academy of Medicine, Singapore, 45(10), 471-474.

*Annushkha Sharanya Sinnathamby
Address: 1E Kent Ridge Rd,
National University Health System,
Singapore 119228
Email: annushkha_sharanya_sinnathamby@nuhs.edu.sg