Submitted: 17 January 2024
Accepted: 14 May 2024
Published online: 1 October, TAPS 2024, 9(4), 57-60
https://doi.org/10.29060/TAPS.2024-9-4/SC3234

Nicole Huiyi Ong¹, Boon Chong Kwok^2,3, Siti Munirah Aman⁴, Steven Michael Dans Macabasco⁵ & Wai Pong Wong²

¹Department of Physiotherapy, Singapore General Hospital, Singapore; ²Health and Social Sciences, Singapore Institute of Technology, Singapore; ³Rehabilitation, Clinical Pilates Family Physiotherapy, Singapore; ⁴Department of Rehabilitation, Outram Community Hospital, Singapore; ⁵Rehabilitation, NTUC Eldercare, Singapore

Abstract

Introduction: Clinical practice education is an important curriculum in developing physiotherapy students to professionals. This curriculum is largely dependent on clinical educators. Although traits of effective clinical educators had been studied in Western population, it was unclear if the Asian population would yield similar traits. Hence, we studied perspectives of students and academic educators to identify top five core traits of an effective clinical educator. The findings will then help guide policy development for clinical educator training and development.

Methods: A survey was circulated to physiotherapy students and academic educators through convenience sampling. We studied 16 traits – enthusiasm, availability, clarity, clinical competence / knowledge, feedback skills, organisational skills, professionalism, well prepared, scholarly activity, non-judgemental, respect students’ autonomy / independence, sincerity, listening skills, evidence-based practice, role model, and awareness of students’ learning needs.

Results: The top five traits identified by students and academic educators were similar in four traits – clinical competency / knowledge, clarity, feedback skills, and enthusiasm, and differed in the choice of “non-judgemental” by students and “awareness of students’ learning needs” by academic educators. Interestingly, when the top six traits were considered instead of five, students and academic educators identified the same traits but in different ranked orders.

Conclusion: The study found six common core traits of an effective clinical educator from the perspectives of students and academic educators. Continuing education development for clinical educators should focus on these six traits prior to other 10 sub-traits.

Keywords:           Training, Development, Education, Allied Health, Entrustable Professional Activities, Mentoring

I. INTRODUCTION

Clinical Practice Education (CPE) is a core component in undergraduate allied health studies, partnering clinicians with additional role as a Clinical Educator (CE) (Gibson et al., 2019). A study evaluating effective residency teaching for doctors identified 15 traits that a CE should possess, which are enthusiasm, competence-knowledge, clarity, availability, non-judgemental, independence, feedback skills, role model, professionalism, sincere, organised, well-prepared, evidence-based practice, scholarly activity and listening skills (Buchel & Edwards, 2005). A recent study found that being aware of the learning needs of students could be the 16^th trait a CE should possess (Francis et al., 2016). Considering recent shift towards the use of the Entrustable Professional Activity framework for work place competency review at student and professional levels (Kwok et al., 2023), it is important to consider which top five traits are considered core competence of a CE as defined by the pinnacle of entrustment at Level 5.

Perspectives of critical traits of an effective CE might differ between students, CEs and academic educators (AEs). Students in early years of undergraduate study and CEs identified similar top five traits of an ideal CE (Cross, 1995). In the study by Cross (1995), CEs should be approachable, possess good communication skills, be knowledgeable and demonstrate enthusiasm in teaching, including clinical competency (Cross, 1995). Competency of CEs was similarly desired among academic educators, alongside “being approachable” and “good communicator”, whereas two differences were noted as compared to CEs and students, which were “interested in learning process of the students” and “concerned about patient care” (Cross, 1995). It is possible that among the Asian population, competency of the CEs would be similarly desired. Recent studies might have considered different trait terms as compared to the classic study, for instance, “learning process” was likely subsumed under “learning needs” (Francis et al., 2016). It is unclear whether the Asian population will present with different trait ranking as compared to Western population.

Therefore, this study was undertaken to identify the top five essential traits of an effective CE. In view of notable differences between perspectives of students and AEs in past literature, this study explored similarities and differences of perspectives between students and AEs. In addition, we explored what gaps might exist in developing CEs. In this study, the AEs, all of whom used to be CEs, could provide useful and important inputs on the traits required of a CE. The findings would then provide directions for future policy development pertaining to clinical education and professional supervision.

II. METHODS

A. Study Design

A survey was conducted through convenience sampling. The study was conducted between March to December 2022. The study was approved by the Institutional Review Board of the Singapore Institute of Technology (SIT-IRB-2022031).

B. Participants

Students in the third year of undergraduate physiotherapy programme and AEs of the physiotherapy faculty (as of April 2022) were involved in the survey. Large variations in response rate exists in convenience sampling, so we projected at least 50% response rate for the students and also the AEs. Students who had withdrawn from the programme were excluded. Associate faculty educators were excluded because they were only involved in ad hoc teaching sessions. Informed consent was sought at the beginning of the survey and digitally recorded.

C. Procedures

The survey described the 16 traits that contribute to an effective CE, which provided participants with knowledge about each trait, which was externally validated by five physiotherapists from the public and private sectors with experience ranging from eight to 25 years. The demographic data included student identification numbers to ensure that each response was unique. Thereafter, the data was de-identified to ensure anonymity during data analysis. As the sample size for the AEs was small, no personal data was collected to ensure anonymity. A survey invitation including a standardised survey link was distributed via email to all eligible participants. Participants were then asked to rank the 16 traits from 1 to 16, with 1 being the most important trait and 16 being the least important. Survey items were not randomised. The online survey was hosted on the secured Qualtrics Survey System (Qualtrics XM, 333 W. River Park Drive, Provo, UT 84604 USA). Student participants were first notified via email, followed by four reminder notifications, two months apart, via the cohort group chat on WhatsApp. AEs were first notified via email, followed by two reminder notifications via WhatsApp three months apart.

D. Statistical Analysis

Data analyses were performed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA). Continuous variables are presented with means (standard deviations) and categorical variables with counts (percentages). Friedman test was used to analyse the mean rank of each trait. Then Kendall’s coefficient of concordance (Kendall’s W) was used to test the level of agreement among students for the mean ranks of the traits, as well as among AEs. The level of agreement was interpreted based on common recommendation and should yield statistical significance at p < 0.05.

III. RESULTS

A total of 81 students completed the survey (response rate of 46.6%) and a total of five AEs completed the survey (response rate of 41.7%). The average age, mean (standard deviation), of the students is 24.5 (4.1) years, and 52 of them are female (64.2%). The traits were ranked and presented in Table 1. Among the top five traits, there were four similar traits found between students and AEs, which were clinical competency / knowledge, clarity, feedback skills, and enthusiasm. The students ranked “non-judgemental” within the top five traits, whereas the AEs identified “awareness of students’ learning needs”. If the top six traits were considered, both students and AEs yielded similar traits. In the traits ranking, the students showed fair level of agreement, approximating closely to moderate agreement, Kendall’s W = 0.38, p < 0.001, while AEs showed moderate level of agreement, Kendall’s W = 0.51, p = 0.001.

Submitted: 19 December 2023
Accepted: 26 April 2024
Published online: 1 October, TAPS 2024, 9(4), 50-56
https://doi.org/10.29060/TAPS.2024-9-4/SC3194

Craig S. Webster¹, Jack Forsythe², Antonia Verstappen¹, Phillippa Poole³, Tim Wilkinson⁴ & Marcus A. Henning¹

¹Centre for Medical and Health Sciences Education, School of Medicine, University of Auckland, Auckland, New Zealand; ²Auckland District Health Board, Te Whatu Ora, Auckland, New Zealand; ³School of Medicine, University of Auckland, Auckland, New Zealand; ⁴Education Unit, University of Otago, Christchurch, New Zealand

Abstract

Introduction: A valid, longitudinal approach is critical for service planning in healthcare and to understand career choice in medical graduates.

Methods: We quantitatively analysed self-reported influences underlying career choice in a national cohort of medical graduates over the first five years of their careers. Participants rated career influences on importance across 26 items using a 5-point Likert scale (1=not at all, 5=a great deal).

Results: We included 659 New Zealand medical graduates (mean 25.4 years old, 376 F, 283 M) from the University of Auckland and the University of Otago, graduating in 2012 and 2013 (85% response rate). Responses were linked longitudinally over their post-graduate years 1, 3 and 5, and underwent principal component analyses. At graduation the factor rated as the most important in career choice had a mean (SD) item score of 3.9 (0.7) and comprised: Medical School Experiences; Specialty Experience; Mentors; and Self-Appraisal – consistent with graduates securing initial employment. Factors which explained the most variance in career choice over the five years after graduation indicated that the costs of medical school and further training were consistently rated as the least important in career choices, while flexibility in working hours were consistently rated as the most important. Factors remained relatively stable over time, showing variation in scores of only a median of 0.5 Likert points, indicating further opportunities for career choice research.

Conclusion: Our results regarding costs of medical training are reassuring, and suggest that greater flexibility in working hours may attract graduates to underserved specialties.

Keywords:           Medical Education, Career Choice, Career Influences, Cost, Debt, Measurement, Medical Graduates, National Longitudinal Study, Working Hours, Work Culture

I. INTRODUCTION

A common strategic aim of medical schools throughout the world is to supply the range of graduates who will best meet the healthcare needs of their communities (Gorman, 2018). However, fulfilling this aim is far from straight-forward, with perhaps the most critical difficulty involving understanding the influences that underlie career choice in medical graduates and how these vary over time.

The financial burden of completing medical school and further training has been one of the most widely studied influences underlying career choice, with suggestions that rising costs may encourage graduates to pursue specialties perceived to be more highly paid, often in cities, thus undersupplying primary healthcare and rural locations. However, in New Zealand medical graduates are otherwise free to choose their preferred career path and choices may be influenced by many things other than training costs and debt, including personal interest, employment conditions, specialty availability and lifestyle preferences (Webster et al., 2020; Webster et al., 2017).

Therefore, in the following, we analyse the self-reported influences underlying career choice in a national cohort of medical school graduates during the first five years of their careers using quantitative data drawn from the existing longitudinal Medical Schools Outcomes Database (MSOD).

II. METHODS

The MSOD project is a bi-national longitudinal questionnaire study that aims to improve healthcare delivery in Australia and New Zealand (Poole et al., 2019). At graduation and in postgraduate years (PGY), graduates are asked to specify their preferred area(s) of medicine, and complete a schedule of influencing items, indicating the degree to which each was important in their choice, using a 5-point Likert scale with anchors of 1 (not at all) to 5 (a great deal) – see Supplementary Table 1 for full question set.

A. Data Analysis

We conducted a series of principal component analyses (SPSS v27, IBM Corporation, New York) of the responses to the 26 influencing item questions at each time point to identify factors within responses, and describe them over time.

III. RESULTS

Data from a national cohort of 659 New Zealand medical school graduates who had graduated from the University of Auckland and the University of Otago in 2012 and 2013 were included. The response rate for completed questionnaires in the Exit cohort was 85% – representing a sampling margin of error of only 1% at the 95% level of confidence. The mean (SD) age of participants in the cohort was 25.4 (2.7) years, with a higher proportion of female graduates (376 F vs 283 M). Over the next five years, this Exit cohort self-reported on the same set of influences underlying career choice at PGY1, PGY3 and PGY5 – maintaining a response rate between 53% and 56%, and a sampling margin of error of 3%.

We used conventional settings during analysis, comprising varimax rotation and suppression of loadings below 0.3. The Kaiser-Meyer-Olkin measure of sampling adequacy across time points demonstrated a median (range) of 0.77 (0.75 to 0.82), indicating distinct and reliable factors at each time point. In addition, Bartlett’s test of sphericity was highly significant at each time point, (2338<c²<3498, p<0.0001), demonstrating correlation with little redundancy in items (Kaiser, 1974).

Submitted: 12 December 2023
Accepted: 25 March 2024
Published online: 1 October, TAPS 2024, 9(4), 40-49
https://doi.org/10.29060/TAPS.2024-9-4/SC3254

Vivien Lee¹, Jeffrey Jiang¹, Anna Szücs¹, V Vien Lee¹, Low Si Hui², Faith Teo¹, Jose M Valderas¹ & Victor Loh¹

¹Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²National University Polyclinics, Singapore

Abstract

Introduction: Globally, persons with disabilities (PWD) face structural and social barriers to inclusive healthcare. Medical schools, as crucibles of medical professional identity formation, have the responsibility to foster person-centredness toward all patients, including PWD, among her graduates. We co-designed with PWD a “Communications with Persons with Disabilities” workshop and evaluated its impact.

Methods: The workshop enlisted PWD as patient educators, occurred within the third-year undergraduate Family Medicine posting, and was designed to positively impact communications skills and attitudes toward PWD. Students (n=135) were surveyed pre- and post- workshop following a mixed-methods approach (demographic data, Attitude Towards Disabled Persons (ATDP)-O scale, feedback questions, and post-workshop free reflections). Descriptive analysis was used for demographic and feedback questions, and thematic analysis for reflections. Paired t-test was used to evaluate change in ATDP-O scores.

Results: There were 69 survey respondents (51.11%). Most students agreed that communications training with PWD could be strengthened in medical school, and that the workshop was relevant to their future medical career (n=68, 98.55%). Attitudes towards PWD significantly improved after the workshop (ATDP-O change: +9.29 points (12.7%), p <0.001). Student reflections included attitudes, such as the importance of seeing the person beyond the disability, and a call for action towards inclusivity and accessibility of care for PWD.

Conclusion: Students’ attitudes were positively affected by involving PWD in the curriculum. Further research is needed for assessing the impact of how a longitudinal PWD curriculum could affect medical trainees and improve social inclusiveness in healthcare practice.

Keywords:           Medical Education, Communication, Persons with Disabilities, Disability, Social Inclusiveness, Student Attitudes, Person Centred Care, Active Learning

I. INTRODUCTION

Globally, persons with disabilities (PWD) face structural and social barriers to inclusive healthcare. In Singapore, few are comfortable with direct personal interaction with PWD (National Council of Social Service Singapore, 2019).

With respect to medical education, different disability curriculum from didactic lectures to longitudinal patient experiences have been described (Ali et al., 2023). Overall evidence suggests that more frequent and positive contact with PWD increased positive attitudes (Ali et al., 2023; National Council of Social Service Singapore, 2019).

Medical schools, as crucibles of medical professional identity formation, have the responsibility to foster person-centredness toward all patients, including PWD, among her graduates. In July 2022, the National University of Singapore’s Division of Family Medicine developed with PWD, piloted and assessed a four-hour experiential workshop for third-year medical students called “Communication with PWD” in July 2022.

The four-hour workshop was prefaced by pre-event reading materials. A plenary started on site learning, followed by fishbowl discussions where student volunteers took turns to perform a clinical consultation with PWD who enacted scripted role-plays. There was a ratio of one tutor and PWD to a group of ten to fifteen students. Each student would encounter three broad categories of disability (vision, hearing, mobility) during the fishbowl sessions. Students interacted with PWD after each role play. Reflections and debrief by tutors would close the workshop.

This study aimed to evaluate the workshop’s impact on students’ attitudes towards PWD for: (Q1) differences in pre-workshop attitudes towards PWD between male and female medical students; (Q2) within-person changes in students’ overall attitudes towards PWD pre-post workshop; (Q3) associations between pre-workshop attitudes towards PWD and personal experience with PWD; and (Q4) exploration of how the workshop has affected students’ attitudes towards caring for PWDs.

II. METHODS

A. Study Design

This study had a mixed methods design including a pre- and post-intervention survey (quantitative), and reflections (qualitative). Students attending the 3^rd and 4^th Family Medicine Rotation (January to March 2023) of Academic Year 2022/23 were invited to participate in the study. The questionnaire was administered in person. Students completed the questionnaires independently. A waiver of consent was applied for reflections. 

B. Survey

The pre-workshop questionnaire comprised demographic information and the 20-item Attitude Towards Disabled Persons (ATDP)-O scale (Yuker et al., 1960). The questions were scored on six-point Likert scale from “I disagree very much” (-3) to “I agree very much” (+3). The post-workshop questionnaire comprised the ATDP-O scale and feedback questions.

We used the original ATDP-O form as it had been used in other studies on medical students (Arabi et al., 2021) and was deemed reliable (reliability coefficient .80) and valid by prior psychometric analyses (Yuker et al., 1960).  Performance in local context was assessed through cognitive testing with five randomly selected medical students who were classmates of study participants and excluded from the study sample.

C. Reflections

Student reflection sheets included a single open-ended statement: “Please pen a question or a reflection you’d like to share from the session today”.  Reflections were transcribed verbatim and de-identified before analysis. All reflections were used to limit selection bias.

D. Data Analysis

Numeric data was analysed by R software (version 4.31). Internal consistency of the scale in our study sample was measured with Cronbach’s alpha. We used two samples independent unpaired t-test to evaluate Q1 (differences in baseline ATDP-O scores between males and females), two samples paired t-test to evaluate Q2 (change in pre-post workshop ATDP-O scores), and two samples independent unpaired t-tests, Welch’s t-tests and Spearman’s correlation tests to evaluate Q3 (difference in baseline ATDP-O scores across different types/levels of contact with PWD). In the evaluation of Q3, two samples independent unpaired t-test was used when two groups have similar sample sizes or similar variances while Welch’s t-test was used when there’s unequal variances or disparate sample sizes between two groups. Spearman’s correlation was used to analyse associations with ordinal variables.

Student reflections were analysed thematically. Four researchers (VLE, VVL, AS, FT) reviewed the data and generated initial codes independently. Multiple discussions were conducted to explore different perspectives and increasingly develop codes. Based on codes generated, potential themes and subthemes were developed over several iterations. Final themes and subthemes were reviewed in relation to the entire dataset.

III. RESULTS

Of 135 students invited, 69 students consented to the study and completed both the pre- and post-workshop questionnaire. The results are summarised (Table 1a and 1b).

Cognitive testing confirmed that students had no difficulties understanding questions nor suggested any edits for clarification. The internal consistency of the scale was α = 0.72 (pre-workshop) and α = 0.78 (post-workshop).

(Q1) Female gender had a significantly higher baseline ATDP-O scores (p = 0.028).

(Q2) There was a significant improvement of 9.29 points (12.7%) in the ATDP-O score post workshop (p <0.001).

(Q3) Previous experience of training to care for PWD (p<0.001) and previous experience caring for PWD (p = 0.033) had significantly lower baseline ATDP-O scores.

 

Results	Number (%)	ATDP-O baseline score Mean (SD)			Statistics
Overall	N=69	72.71 (10.46)
By age (Mean = 21.59, SD = 0.96)					Pearson’s r(67) = – 0.02, p = .857
By gender
Female	37 (53.62%)	75.32 (8.61)			t(67)  = 2.30, p = .025*
Male	32 (46.38%)	69.69 (11.69)
By ethnicity
Chinese	56 (81.16%)	73.18 (10.20)			F(2, 66) = 1.64, p = .201
Indian	12 (17.39%)	69.33 (11.18)
Others	1 (1.45%)	87.00 (.)
Self-reported disability
No	66 (95.65%)	72.74 (10.59)			t(2) = 0.14, p = .900
Yes	3 (4.35%)	72.00 (8.89)
Self-reported training to care for PWD
No	67 (97.10%)	73.06 (10.42)			t(7) = 7.45, p < .001*
Yes	3 (4.35%)	61.00 (1.41)
Self-reported frequency of care for PWD (ranked variable ranging from never = 1 to often = 4)
Never	34 (49.28%)	75.7 (9.5)			Spearman’s rho(67) = – 0.26, p = .033*
Rarely	22 (31.88%)	69.8 (11.8)
Sometimes	12 (17.39%)	69.5 (9)
Often	1 (1.45%)	75 (.)
Self-reported knowledge of PWD who is important to them
No	53 (76.81%)	73.57 (10.95)			t(67) = 1.24, p = .219
Yes	16 (23.19%)	69.88 (8.34)
Self-rated likelihood of pursuing career in Family Medicine (ranked variable ranging from very unlikely = 1 to very likely = 5)
Very likely	9 (13.04%)	72.1 (10)			Spearman’s rho(67) = 0.03 , p = .803
Likely	18 (26.09%)	73.2 (11.5)
Undecided	37 (53.62%)	73.5 (10.3)
Unlikely	4 (5.80%)	63.5 (8.9)
Very unlikely	1 (1.45%)	78 (.)
Do you feel your education about persons with disabilities in medical school has been adequate so far?
Agree	1 (1.45%)		–		–
Neither disagree nor agree	19 (27.54%)		–		–
Disagree	42 (60.87%)		–		–
Strongly disagree	7 (10.14%)		–		–
Would you find it important to include education and training on persons with disabilities?
Strongly agree	23 (33.33%)			–	–
Agree	39 (56.52%)			–	–
Neither disagree nor agree	5 (7.25%)			–	–
Disagree	1 (1.45%)			–	–
Strongly disagree	1 (1.45%)			–	–
Do you feel that the education provided during the Communications with Persons with Disabilities workshop was relevant to your future career as doctors?
Strongly agree	45 (65.22%)			–	–
Agree	23 (33.33%)			–	–

Table 1a. Baseline ATDP-O scores and curriculum feedback

 

Results	ATDP-O score Mean (SD)	Pre-Post workshop comparison statistics
Descriptive statistics
Pre-workshop ATDP-O score	72.71 (10.46)	t(68)  = 8.69, p < .001*
Post-workshop ATDP-O score	82.00 (11.46)
Difference in ATDP-O scores
Overall sample	9.29 (8.88)	t(68)  = 8.69, p < .001
By age (Mean = 21.59, SD = 0.96)		Pearson’s r(67) = – 0.06, p = .643
By gender
Female	8.62 (9.33)	t(67) = – 0.67, p = .505
Male	10.06 (8.41)
By ethnicity
Chinese	9.02 (9.45)	F(2, 66) = 0.15, p = .859
Indian	10.33 (6.21)
Others	12.00 (.)
Self-reported disability
No	9.50 (8.06)	t(2) = 0.36, p = .752
Yes	4.67 (23.12)
Self-reported training to care for PWD
No	9.09 (8.92)	t(1) = – 2.17, p = .230
Yes	16.00 (4.24)
Self-reported frequency of care for PWD (ranked variable ranging from never = 1 to often = 4)
Never	8.8 (6.1)	Spearman’s rho(67) = 0.05, p = .678
Rarely	11.5 (9.1)
Sometimes	9.4 (10.8)
Often	-22 (.)
Self-reported knowledge of PWD who is important to them
No	10.72 (7.61)	t(67) = 2.52, p = .014*
Yes	4.56 (11.20)
Self-rated likelihood of pursuing career in Family Medicine (ranked variable ranging from very unlikely = 1 to very likely = 5)
Very likely	10.4 (9.2)	Spearman’s rho(67) = 0.07, p = .547
Likely	10.9 (7.8)
Undecided	7.9 (9.5)
Unlikely	11.5 (9.3)
Very unlikely	11 (.)

Table 1b. Difference in ATDP-O scores post workshop

Most students found the workshop a positive experience and reported feelings of thankfulness and inspiration towards patient educators. Four themes emerged from the students’ post-workshop reflections, of which we highlight those related to attitudes – Humanizing mindsets towards PWD (Theme 1) and Call for action towards inclusivity and accessibility (Theme 2). The other themes were Knowledge and Skills, as students included knowledge and communication skills they acquired during the workshop (Appendix 1 and 2).

A. Theme 1 – Humanising Mindset towards Persons with Disabilities

Students expressed attitudes of empathy, sensitivity, and humanising care through viewing PWD as individuals beyond their disabilities. A student reflected

“Being able to speak to members of these respective communities helped me to understand how empowered PWD can be… It is essential that [PWD] are treated as exactly that, [and] not characterised by their disabilities.”

On providing care for PWD, students noted the distinction between empathy and sympathy, and highlighted the importance of empathy instead of pity. As summed up by a student,

“Not to sympathise but to empathise. Not to see them and pity them”

B. Theme 2 – Call for Action towards Inclusivity and Accessibility

Concurrent with attitudes expressed in the reflections, students discussed the need to improve inclusivity and accessibility from an individual and societal perspective. One student wrote,

“As doctors, we need to try our best to alleviate their disease burden, and at the same time, make their journey to accessing healthcare more seamless with less barriers.”

Beyond self-improvement, students were aware of the need to shift their own perspectives of disability from a medical to a social model. Students also reflected the need for greater national efforts towards societal inclusivity for PWD. A student reflected,

“I think policymakers and organisations should periodically involve PWD to [better] take their needs into consideration as they have the right to integrate into our society just as much as everyone else.”

IV. DISCUSSION

Our study showed positive change in attitudes towards PWD among medical students after a workshop with improvement of 9.29 points in the ATDP-O score (Table 1b), reinforced by their post-workshop reflections. To our knowledge, this is the first study in Asia evaluating an educational intervention focusing on communications skills training with PWD. Based on student reflections, the communications workshop was effective in developing knowledge and communication skills, prompting the key attitudes of humanizing care, and a call for action towards societal inclusivity and accessibility towards PWD.

We intentionally had PWD co-designing the workshop and playing key roles as patient educators. Student reflections support these curriculum design decisions. Our work coheres with literature that a contact-based approach with PWD would be impactful: reducing anxiety and improving empathy levels, rather than more theoretical approaches to promote attitudes towards PWD (Arabi et al., 2021).

Our study corroborates the widely reported result that female gender positively influenced baseline attitudes towards PWD in medical students (Satchidanand et al., 2012). A possible explanation is females having a propensity to exhibit more empathetic feelings toward others. There is a greater change in attitudes in males than females after the workshop, but this change is not significant.

In contrast to prior research that consistently associated increased contact with PWD with more positive attitudes (Satchidanand et al., 2012), we found that having previous experience with PWD influenced baseline ATDP-O scores negatively (Table 1a). Moreover, there was a significantly smaller change in ATDP-O scores if they knew a PWD who is important to them (Table 1b). A possible explanation is “caregiver fatigue” due to unavailability of support to allow adequate care for PWD (Arabi et al., 2021). The type of previous experience may thus be key factors in shaping current attitudes towards PWDs.

This study has several limitations. We cannot determine if positive change in attitudes post-workshop would translate into changes in clinical practice in the future. The survey was not compulsory for students, potentially leading to selection bias. We tried to overcome the selection bias by including all student reflections.

V. CONCLUSION

There was significant improvement in students’ attitudes towards PWD post-workshop, as shown through the ADTP-O score and reflection analysis. Medical students benefit particularly from the fishbowl discussions which allows students to interact with persons with disability, growing our future generations of healthcare professionals who humanise care.

Notes on Contributors

Author VLE conceptualised the study, developed the methodology, conducted the investigation, did the formal analysis and visualization of data, wrote the original draft, reviewed and edited the manuscript. Author JJ conceptualized the study, developed the methodology and original draft, reviewed and edited the manuscript. Author AS developed the methodology, did the formal analysis of data, reviewed and edited the manuscript. Author VVL did the formal analysis of data, wrote the original draft, reviewed and edited the manuscript. Author LSH did the formal analysis and visualization of data. Author FT did the formal analysis, reviewed and edited the manuscript. Author JMV supervised the conceptualization and methodology of the study, reviewed and edited the manuscript. VLO supervised the conceptualization of the study, developed the methodology, reviewed and edited the manuscript. All authors have read and agreed to the published version of the manuscript.

Ethical Approval

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of the National University of Singapore on 11 November 2022 (NUS-IRB-2022-608).

Data Availability

Quantitative data repository can be freely accessed at: https://doi.org/10.6084/m9.figshare.24013134  

Qualitative data repository can be freely accessed at: https://doi.org/10.6084/m9.figshare.24051195  

Funding

There was no funding for this research study.

Declaration of Interest

Authors VLE, JJ and VLO are tutors in the “Communications with Persons with Disabilities” workshop. There are otherwise no other conflicts of interest.

References

Ali, A., Nguyen, J., Dennett, L., Goez, H., & Rashid, M. (2023). A scoping review for designing a disability curriculum and its impact for medical students. Canadian Medical Education Journal, 14(3), 75–86. https://doi.org/10.36834/cmej.74411

Arabi, H., Adarmouch, L., & Ahmed Eladip, G. (2021). The assessment of student doctors’ attitude towards disabled people after teaching them a module. Acta Bio-Medica: Atenei Parmensis, 92(2), e2021059. https://doi.org/10.23750/abm.v92i2.9547

National Council of Social Service Singapore. (2019). Public Attitudes Towards Persons with Disabilities 2019. https://www.ncss.gov.sg/docs/default-source/ncss-publications-doc/pdfdocument/public-attitudes-towards-persons-with-disabilities-2019-infographics.pdf

Satchidanand, N., Gunukula, S. K., Lam, W. Y., McGuigan, D., New, I., Symons, A. B., Withiam-Leitch, M., & Akl, E. A. (2012). Attitudes of healthcare students and professionals toward patients with physical disability: A systematic review. American Journal of Physical Medicine & Rehabilitation, 91(6), 533–545. https://doi.org/10.1097/PHM.0b013e3182555ea4 

Yuker, H. E., Block, J. R., & Campbell, W. J. (1960). A scale to measure attitudes toward disabled persons. In Human Resources Study Number 5. Human Resources Foundation.

*Vivien Lee
1E Kent Ridge Rd,
Singapore 119228
Email: vivienl@nus.edu.sg

Submitted: 3 April 2024
Accepted: 22 July 2024
Published online: 1 October, TAPS 2024, 9(4), 33-39
https://doi.org/10.29060/TAPS.2024-9-4/OA3282

Meltem Saygılı¹, Aysun Kandemir Türe¹ & Şirin Özkan²

¹Department of Health Management, Kırıkkale University, Kırıkkale, Türkiye; ²Department of Medical Services and Techniques, Vocational School of Health Services, Uludag University, Türkiye

Abstract

Introduction: Many societal changes threaten the sustainability of health systems. Entrepreneurs play a significant role in creating sustainable innovations necessary for development and structural change. This study aimed to evaluate how university students studying health sciences perceive individual entrepreneurship during the COVID-19 pandemic and to explore the impact of COVID-19-related hopelessness on their perception of entrepreneurship.

Methods: Six hundred eighty-one undergraduate students from the faculty of health sciences in Türkiye, participated in the study. The Individual Entrepreneurship Perception Scale and Beck Hopelessness Scale were used to collect data.

Results: The results revealed that the students’ perception of individual entrepreneurship was high, while their hopelessness levels were moderate. In addition, a moderate negative relationship was found between the students’ hopelessness levels and their perception of individual entrepreneurship. The regression analysis showed that the students’ hopelessness levels and sub-dimensions (hope, loss of motivation, and future expectation) accounted for 26.3% of the total variance in individual entrepreneurship perception. Increased hopelessness regarding the sub-dimensions of hope, loss of motivation, and expectations for the future decreased their individual entrepreneurship perceptions.

Conclusions: These findings suggest that individual entrepreneurship perception among health sciences students could be negatively impacted during extraordinary periods related to health crises like pandemics. Developing hope, motivation, and expectations for the future is crucial to enhancing individual entrepreneurship perception among health sciences students.

Keywords: Individual Entrepreneurship Perception, Hopelessness, Health Sciences, University Students, COVID-19 Pandemic

Practice Highlights

• University education plays a critical role in developing students’ perceptions of entrepreneurship.
• Students’ perceptions of entrepreneurship are affected by changing environmental conditions.
• The COVID-19 pandemic has led to a significant increase in awareness of Healthcare Entrepreneurship.
• The COVID-19 pandemic has negatively affected students’ expectations and hopes for the future.
• Health sciences students experienced the psychological effects of the pandemic more intensely.

I. INTRODUCTION

Entrepreneurs are described as individuals who “implement bold new ideas from the outset, taking on the risks of the business or venture that enables innovation to happen” (Suryavanshi et al., 2020). Entrepreneurship education seeks to provide students with in-depth knowledge, motivation, and skills to increase entrepreneurial intentions’ success in various settings (Sampene et al., 2023). In developing economies such as Türkiye, government efforts to improve unemployment conditions are directed towards developing students’ positive attitudes towards entrepreneurship and increasing their interest in self-employment.

Universities are crucial in developing students’ entrepreneurial intentions (Bagheri, 2018). It is critical to examine and develop the entrepreneurial potential of university students trained to fulfill important roles in the field of health services in the future. This is because students and newly graduated healthcare professionals with entrepreneurial skills are now needed to develop innovative healthcare delivery models that can improve the quality of healthcare services, improve treatment outcomes, and reduce the cost of care (Fashami et al., 2021; Mohamed et al., 2023). It is stated that healthcare is one of the main industrial areas where user entrepreneurship takes place worldwide (Schiavone et al., 2020) and the pandemic environment brings unique opportunities for entrepreneurs, especially in healthcare. However, research shows that fear and worry due to the COVID-19 pandemic are making the future workforce anxious and hopeless about their professional futures (Duplaga & Grysztar, 2021; Tao et al., 2023). In such an environment, it is predicted that university students, especially those who are trained to work in health service delivery, may act in different ways in their decisions about their professional future.

Because an individual’s perception of current conditions can significantly, positively, or negatively affect the formation of entrepreneurial intentions and the likelihood of starting an enterprise (Krichen & Chaabouni, 2022). Considering the increasing entrepreneurship opportunities in healthcare and the negative effects of the COVID-19 pandemic on healthcare services, it has become important to address the entrepreneurship perceptions of students who will serve in this field in the future and to evaluate the hopelessness experienced. When the literature was examined, no other research addressing entrepreneurship in the context of hopelessness was found. Therefore, we believe that our research findings will make a valuable contribution to filling this gap in the literature.

A. Universities, Health Sciences Education and Entrepreneurship

Recent years have focused on the role of universities in industrial competitiveness and their impact on social change (Hart & Rodgers, 2023), and universities in teaching and initiating entrepreneurship have emerged as leading actors. Recent research examining students’ attitudes toward entrepreneurship reveals that universities have a critical role in developing entrepreneurial spirit and perceptions of entrepreneurship in students (Krichen & Chaabouni, 2022; Liao et al., 2022; Sampene et al., 2023). Moreover, university students now value real experience more and prefer universities that offer entrepreneurship opportunities and experiences (Taneja et al., 2024).

Universities providing education in healthcare have traditionally emphasised vocational training and unfortunately, there are very few university programs with curricula that focus on innovation and entrepreneurship in healthcare (Suryavanshi et al., 2020). Consequently, most newly graduated physicians and other healthcare professionals start their careers without the knowledge, experience, and courage to integrate their medical knowledge with the healthcare business world, and thus are unable to commercialise new healthcare delivery methods (Boore & Porter, 2011).

B. Hopelessness Experienced by Students Due to the COVID-19 Pandemic and Perception of Individual Entrepreneurship

Students are one of the groups that experience the psychological effects of the pandemic most intensely (Marahwa et al., 2022). Studies conducted with students during the pandemic period showed that students experienced higher levels of anxiety and depressive symptoms due to uncertainties about the future and the negative effects of the pandemic on their educational lives (Alnıaçık et al., 2021; Hajinasab et al., 2022; Kaplan Serin & Doğan, 2023; Zhang et al., 2021). Moreover, it was also determined that students’ hopelessness levels were higher in the first wave of the pandemic and during the quarantine period and decreased with normalisation (Tao et al., 2023). In addition, it has been found that students who are educated in the field of health and have clinical experience are more anxious and hopeless than undergraduate students who are educated outside the field of health (Pretorius, 2021). Although entrepreneurship is a future-oriented orientation and is perceived as the ability to turn negative situations into opportunities, it is estimated that the psychological effects of COVID-19 may negatively affect entrepreneurial intention in students. Therefore, this study aims to examine the effect of hopelessness experienced by health sciences faculty students during the COVID-19 pandemic on their perception of individual entrepreneurship.

II. METHODS

A. Sampling and Participants and Data Collection

The study was conducted with university students studying at the Faculty of Health Sciences in Türkiye. The faculty consists of six departments, namely Physiotherapy and Rehabilitation, Health Management, Social Work, Nutrition and Dietetics, Child Development and Nursing, and has 2335 students. The sample size required for the study was calculated using the formula (n=[z²xp(1-p)/d²]/1+[z²xp(1-p)/d²N]) and it was determined that a minimum of 337 participants would be sufficient with a 5% error level and 95% confidence level. Participants were selected using a simple random sampling technique and volunteerism was taken as a basis in obtaining the data. The study was conducted between April and May 2022 and 681 valid questionnaires were returned from the participating students.

Data were collected using the socio-demographic information form, Individual Entrepreneurship Perception Scale, and Beck Hopelessness Scale. The Individual Entrepreneurship Perception Scale is a 5-point Likert scale consisting of 31 items and six sub-dimensions: planning, locus of control, self-confidence, communication, motivation, and self-discipline. This scale was developed by Incik and Uzun in 2017 to assess university students’ perceptions of entrepreneurship. The reliability coefficients (Cronbach’s Alpha) of the sub-dimensions of the Individual Entrepreneurship Perception Scale and the total scale were found to be 0.80, 0.84, 0.75, 0.75, 0.75, 0.72, 0.75, 0.60 and 0.92, respectively (Incik & Uzun, 2017). For this study, it was determined that the Cronbach Alpha values of the Individual Entrepreneurship Perception Scale ranged between 0.69 and 0.93 (Table 2).

The Hopelessness Scale was initially developed by Beck et al. in 1974 and subsequently adapted into Turkish by Durak and Palabıyıkoğlu in 1994. This scale comprises 20 items divided into three sub-dimensions: expectations for the future, loss of motivation, and hope. Each question in the scale requires a ‘yes’ or ‘no’ response, and the maximum achievable score is 20. An increase in the overall score denotes a higher level of hopelessness. The reliability coefficients for the sub-dimensions of the scale were calculated to be 0.78, 0.72, and 0.72, respectively (Durak & Palabıyıkoğlu, 1994). Table 2 presents the Cronbach’s alpha coefficients for the sub-dimensions and the scale, which were found to be 0.75, 0.77, 0.74, and 0.88, respectively.

B. Statistical Analysis

The statistical analyses used were performed in SPSS v23.0. Descriptive analyses such as percentage, mean, standard deviation, reliability analysis (Cronbach’s Alpha), and normality tests were performed to obtain the results. To test the normal distribution, kurtosis, and skewness values were calculated for each scale’s sub-dimensions and total scores. It was determined that the values obtained were in the range of -1.5 to +1.5 and the data showed a normal distribution (Tabachnick & Fidell, 2013). The results of the analysis are presented in Table 2. In addition, multiple linear regression analysis was used to investigate the relationship between hopelessness and students’ perception of individual entrepreneurship.

III. RESULTS

The study involved students with an average age of 21.3 years, ranging from 18 to 44 years old. 86% of the participants were female students, and the majority (52.3%) reported a grade point average of 3 or above (with a scale of 0 to 4). 68.3% of the students lived in the city center with their families. Among the students’ mothers, 37.7% had a primary school graduate degree, and 81.4% were not working. On the other hand, 32.2% of the students’ fathers had a high school graduate degree, and 78.4% were actively working. Most of the students (68.3%) stayed in dormitories. Regarding career plans after graduation, most students expressed their interest in working in a health institution (public or private). At the same time, only 15.6% said they wanted to start their own business. 15% of the students were still undecided about their work plans (Table 1).

Submitted: 21 February 2024
Accepted: 16 July 2024
Published online: 1 October, TAPS 2024, 9(4), 26-32
https://doi.org/10.29060/TAPS.2024-9-4/OA3255

Aletheia Chia¹, Menghao Duan¹ & Sashikumar Ganapathy^2,3

¹Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore; ²Department of Emergency Medicine, KK Women’s and Children’s Hospital, Singapore; ³Paediatric Academic Clinical Programme, Duke-NUS Medical School, Singapore

Abstract

Introduction: Mentoring is an essential component of post-graduate medical training programs worldwide, with potential benefits for both mentors and mentees. While factors associated with mentorship success have been described, studies have focused on intrapersonal characteristics and are largely based in Western academic programs. Mentorship occurs in a broader environmental milieu, and in an Asian context, cultural factors such as respect for authority, hierarchy and collectivism are likely to affect mentoring relationships. We aim to explore the lived experience of mentors within an Asian postgraduate medical training program, and thus identify challenges and develop best practices for effective mentoring.

Methods: 14 faculty mentors from a post-graduate paediatric residency program were interviewed between October 2021 to September 2022. Data was collected through semi-structured one-on-one interviews, with participants chosen via purposeful sampling. Qualitative analysis was done via a systematic process for phenomenological inquiry, with interviews thematically coded separately by 2 independent reviewers and checked for consistency.

Results: 4 main thematic concepts were identified: “professional, but also personal”, “respect and hierarchy”, “harmony and avoidance of open conflict” and the “importance of trust and establishing a familial relationship”. Mentors also highlighted the value of structure in Asian mentoring relationships.

Conclusion: Cultural factors, which are deeply rooted in social norms and values, play an important role in shaping mentoring relationships in an Asian context. Mentoring programs should be tailored to leverage on the unique cultural norms and values of the region in order to promote career growth and personal development of trainees and mentors.

Keywords:           Medical Education, Graduate Medical Education, Professional Development

Practice Highlights

• Cultural factors are key in shaping Asian mentoring relationships.
• This includes being ‘professional, but also personal’, ‘respect and hierarchy’, ‘harmony and avoidance of open conflict’ and the “importance of trust and establishing a familial relationship’.
• Mentoring programs should be tailored to leverage on the unique local cultural norms and values.

I. INTRODUCTION

Mentoring is an essential component of post-graduate medical training programs worldwide. Mentorship is a reciprocal, interdependent relationship between a mentor (often a faculty member who is senior and experienced) and a mentee (beginner or protégé in the field) (Sambunjak et al., 2006). Benefits for mentees include aiding career preparation, development of clinical and communication skills, independence, and preventing burnout (Flint et al., 2009; Ramanan et al., 2006; Spickard et al., 2002). Mentors derive satisfaction from aiding the next generation, motivation for ongoing learning and institutional recognition (Burgess et al., 2018).

Variables associated with mentoring success have been described. Key components identified by mentors and mentees are communication and accessibility, caring personal relationship, mutual respect and trust, exchange of knowledge, independence and collaboration, and role modelling (Eller et al., 2014). Personality differences, lack of commitment, conflict of interests and mentor’s lack of experience can contribute to unsuccessful mentoring relationships (Straus et al., 2013).

However, mentorship occurs in a broader environmental milieu. Sambunjak (2015) described an ecological model of mentoring in academic medicine, with a first societal level of cultural, economic and political factors; a second institutional level of system- and organisation-related factors, and a third level of intrapersonal and interpersonal characteristics. Studies on mentorship have mainly focused on the latter and are situated in Western academic programs. In an Asian context, cultural factors such as respect for authority, hierarchy and collectivism may affect mentoring relationships (Chin & Kameoka, 2019). Trainees may show more deference to their mentors, and mentors may be more directive than collaborative. An Asian study surveying Doha’s postgraduate paediatric program found 75% mentees unsatisfied in their mentoring relationship (Khair et al., 2015).

We aim to explore the lived experience of mentors within an Asian postgraduate medical training program, and thus identify the challenges faced by trainees and mentors and develop best practices for effective mentoring.

II. METHODS

A. Study Design

This qualitative study is based on an interpretive phenomenological approach of participants’ lived experiences in their mentoring relationships. Through close examination of individual experiences, phenomenological analysis seeks to capture the meaning and common features, or essences, of an experience (Starks & Trinidad, 2007).

Semi-structured interviews were conducted. The interview guide was designed to follow a pre-determined structure whilst allowing for flexibility in probing. It was based on insights from literature on key socio-cultural determinants of successful mentoring relationships. Data was collected until saturation, with no new themes emerging.

B. Setting

We studied a paediatric residency program of a tertiary academic centre in Singapore, with 47 residents and 180 faculty members.

A formal mentorship program (Figure 1) has been in place since 2010. Residents indicate preferred faculty mentors at the start of residency, and are advised to consider specialty of interest, characteristics, and gender. Matches are subject to availability, review by the residency program, and mentor acceptance. Residents have one formal mentor throughout the 6 years unless the mentorship is terminated by mutual agreement between mentor and mentee.

Figure 1. Mentorship program structure, with suggested meeting timings and requisite forms. Meetings are required minimally 6-monthly and are scheduled on an ad-hoc basis by the mentor and mentee.

C. Participants

Purposive sampling to identify mentors in the residency program who would provide comprehensive and relevant insights. Considerations included age, gender, race, and years of mentorship and faculty experience. Study members and their mentors were excluded.

Study information sheets were provided to participants with assurance of confidentiality, and written informed consent obtained from each participant. The study was approved by the SingHealth Institution Review Board.

D. Analysis

Qualitative analysis was done via a systematic process for phenomenological inquiry (Creswell & Creswell, 2022), whereby statements were analysed and categorised into clusters of meaning that represent phenomenon of interest. Transcripts were interpreted independently by 2 reviewers (AC, MD) and reviewed by a 3rd study member (SG). Iterative data analysis and collection was performed, with coding done after each interview to identify new themes and inform further interviews.

III. RESULTS

We interviewed 14 mentors from October 2021 to September 2022. 8 were male and 6 were female. 12 were Chinese, 1 Indian, and 1 of other ethnicity. This was representative of faculty demographics. Mentors had two to eleven years of mentorship experience within the program, and one to five existing and prior mentees.

Mentors described their lived experiences in their mentoring journey, providing insights into key values and their relationships’ evolution. 4 main thematic concepts were identified: “professional, but also personal”, “respect and hierarchy”, “avoidance of open conflict” and the “importance of trust”. Mentors also highlighted the value of structure in Asian mentoring relationships.

A. Professional, but also Personal

All mentors agreed that the relationship was predominantly professional, with their key role being that of professional and career guidance. They described their roles as:

“Guidance through difficult decisions or challenges” (#1), “leaning the real world of medicine” (#2), “driving professional development” (#12) and providing “timely and wise advice to support the journey” (#13)

Relationships “predominantly focused on professional or educational aspects… as that’s what it was meant to be” (#10), and were “mainly limited to career-related matters (#11)”.

However, many also identified personal connection as key. While the focus was primarily professional, awareness of personal or emotional aspects aided in understanding their mentors to further professional development and psycho-emotional growth. This included sharing of family lives, and emotional difficulties faced at work.

As the journey progresses it becomes a lot more about the psycho-emotional aspect, and about their mental health and personal well-being. (#1)

A lot of time is spent discussing family issues. If we knew more about the personal life of our mentee it’s so much easier to tailor the advice based on the individual’s unique circumstances. (#3)

A minority of mentors kept their relationship strictly professional and preferred not to talk about aspects outside of work, as it was ‘easier’ (#10) and shared concerns of ‘overstepping certain norms’ (#11).

B. Respect and Hierarchy

Respect was a key factor brought up when exploring the socio-cultural aspects of mentoring in our Asian community. Mentors varied in their opinion as to the extent that this resulted in a hierarchical relationship, and if this had a negative or positive impact on the relationship.

All agreed that respect is a key value in mentoring relationships:

Culturally there’s a large part to play as we’re taught to respect our elders. (#1)

Respecting elders – definitely it’s more prominent in our Asian culture. (#2)

Many mentors highlighted that this resulted in a hierarchical relationship. This manifested in the way senior doctors were addressed strictly by title, polite communication, and consideration of what would be ‘proper’ to discuss or ask a mentor to do.

The hierarchical kind of mindset is still very strong, and is something that is not necessarily healthy. (#4)

You would always see your mentor as someone higher than you. It’s similar to the way in our Asian context we see our parents. a certain sense of distance (#11).

The way medicine is a 师傅徒弟 kind of thing (‘master and disciple’) (#13)

Many shared that this could be a barrier to open communication with juniors wanting to “respect and agree” with their mentors (#14), slowing the growth of some relationships.

No matter how much honesty and trust there is. If they want to say something that their mentor is not happy to hear, or strikes them as being a bit rude or disrespectful – they won’t say it. (#1)

Our culture does say to respect your senior, don’t argue and don’t disagree with your senior. Sometimes they’re not very vocal, ‘ok sir ok sir’. And then later you find out they have certain issues. (#9)

One mentor felt that hierarchy did not play a large part in his mentoring relationships. This was possibly personality related, describing himself as naturally “quite informal”.

Mentors also highlighted factors that mitigated the hierarchical nature of their relationship. This included time, and setting clear boundaries and goals of the relationship.

When we give… a clear boundary and aim with no go zones, then culture may not necessarily be that important anymore (#10)

A minority of mentors felt that hierarchy and respect was not a limiting factor in their relationships:

If the primary aim is having someone to offer you guidance and a different point of view, even if the mentee sees you as someone who is not equal, you can still have that effectiveness. (#11)

C. Harmony, Avoiding Open Conflict and Confrontation

Another socio-cultural concept highlighted was the avoidance of confrontation. While some of this was linked to avoiding disagreements given the hierarchical nature of the relationship, avoiding open conflict and striving for harmony was also a key factor.

Rather than openly bringing up something, to avoid being confrontational we have evolved other means of trying to work our way through that conflict. There is a conscious and deliberate effort to avoid open and confrontational conflict. (#3)

When I was in the UK, they really questioned their mentors quite a lot – almost like a quarrel. That kind of questioning style may not be that well received in our own culture. (#2)

When mentees had differing opinions from their mentors “they would rather not talk about the topic again, or just ask someone else” in order to preserve the relationship (#1).

Within our program, this resulted in difficulties in exiting the relationship to avoid “offending” the mentor:

When the mentor-mentee relationship is breaking down, culturally it can be more difficult for mentees to request to swap. That’s very detrimental to both the mentor and the mentee in the long run. (#1)

This also manifested in avoiding overly ‘emotional’ discussions, with discussion often being more “superficial”, “reserved” (#7) and “factual” (#5) in nature.

Conversely, one mentee shared that younger mentees being of a “younger generation” were more open to speaking their mind, and that this would continue to evolve.

D. Importance of Trust and Establishing a Familial Relationship

In exploring key values for successful mentoring relationships, many highlighted the importance of trust and building up an established relationship.

Chemistry and compatibility when starting out was key. Mentors often felt more comfortable if there was a pre-existing relationship they had their mentors and had “shared commonalities and chemistry”. Honesty and trust were key in enabling the relationship to progress. This included respecting each other’s confidentiality. Relationships without trust was difficult as mentors “had to keep guessing what they want”, and “whatever you plan may not be the real goals of what they actually want” (#2). Over time, establishing the relationship made it easier to confide in each other, overcoming boundaries brought on by hierarchy.

It’s about forming relationships before you can start reflecting with the person. Over time we get to know each other, and seeing that what is shared is truly kept private and confidential. Once we have trust among each other it (reservations) doesn’t become a barrier. (#7)

There must be a certain comfort and trust level before one readily does share vulnerabilities. (#2)

This can be enabled by being approachable, and creating safe environments where mentors can share their difficulties without consequence. However, this could be compromised if mentors have to take up a supervisory role or be involved in remediation processes.

Mentors who developed close and trusting relationships with their mentees described it as familial in nature. This could be as a big brother or sister who would give advice to their younger siblings in non-threatening and neutral ways. It was also described by one mentor as parental in nature.

One interviewer highlighted that whilst Asian cultural factors may limit mentoring, there were also potential benefits:

We must find the best of both worlds. The independence that the Western systems have is good, but Asians tend to be better at teamwork and team spirit. (#13)

E. Value of Structure in an Asian Mentorship Relationship

Many mentors highlighted the value of having a framework for their mentoring relationship. Formalisation of the relationship and having a structure provided a foundation for discussions and enabled them to set boundaries. This prevented it from becoming awkward or “random and situation-based” (#15), and also helped faculty who were “still learning the whole journey of mentoring” (#7).

When we don’t know what to talk about it becomes quite awkward and uncomfortable. But if in the Asian context the mentor brings to it some structure, and they respect that structure, that structure is helpful. (#10)

A minority of mentors felt having a framework was too rigid or unnecessary.

The structure must be there to guide the mentors, but the mentors chosen must also be of a certain maturity so they can find their own way. We must not be too prescriptive or rigid. (#13)

IV. DISCUSSION

In this study, we explored the lived experiences of mentors within an Asian paediatric postgraduate training program. Existing studies have explored characteristics of effective and ineffective mentor relationships, but less is known about the impact of sociocultural factors. Key thematic concepts identified such as “respect and hierarchy” and “avoidance of open conflict” highlighted the importance of cultural factors in shaping mentoring relationships in an Asian context. These are deeply rooted in social norms and values of the region.

Hierarchy is a fundamental aspect of many Asian cultures, where individuals are expected to show respect and deference to their ‘elders’ or those in positions of authority. This was also observed in other Asian communities. A study in postgraduate medicine in Japan found that mentees had an inner desire to “respect the mentor’s ideas”, with both mentees and mentors embracing “paternalistic mentoring” (Obara et al., 2021). In our interviews, this was most apparent in the way mentees addressed their mentors: by title and respectfully. On a deeper level, this was a barrier to open communication. Open sharing was identified as crucial for a constructive mentoring relationship (Burgess et al., 2018), with the lack of it a cause of failed mentoring relationships (Straus et al., 2013).  The willingness to share personal experiences by both mentors and mentees is key for effective mentoring and career growth. Additionally, this is not conducive to fostering creativity and innovation, which are increasingly important in the medical profession.

Communication was also affected by avoidance of open conflict and confrontation. Asian cultures have been described as collectivist, where the needs of the group take precedence over that of the individual, and intragroup harmony is paramount (Chin & Kameoka, 2019). In mentoring relationships, this translates to prioritising a successful and harmonious relationship over personal goals. Indirect communication styles are also more common in many Asian cultures. This has been described as high-context communication, whereby “most of the information is either in the physical context or internalised in the person, while very little is in the coded, explicit, transmitted part of the message” (Hall, 1976). Relying on indirect language nonverbal cues rather than explicitly stating one’s thoughts and feelings can hinder open communication.

Hierarchy and a lack of open communication may result in mentors taking on the role of advisors or coaches rather than true mentors. While there is no universal definition of mentorship, key features are that of a long-term dyadic relationship that encompasses educational, training and professional aspects that is personal and reciprocal (Sambunjak & Marusic, 2009). This is in contrast to tutors or coaches that primarily exhibit educational functions, or counsellors that exhibit personal functions. If the mentor-mentee relationship if influenced by hierarchical norms, mentors may be seen as figures of authority rather than partners in development. Cultural respect for authority figures and an emphasis on conformity may also discourage mentees from questioning or having open conversations with their mentors, limiting mutual learning.

Challenges with hierarchy and communication can be overcome with the aid of a structured program, and eventually establishment of trust and ‘familial’ relationships.  A structured program can guide mentors and mentees in having open communication. In an Asian context, mentors may initially play a more authoritative role in guiding and directing their mentees with the aid of a structured guide, from which more two-way communication may open up as the relationship becomes more established. Whilst desirable mentors have characteristically been described as not “bossy” or authoritative (Sambunjak & Marusic, 2009), a study of Japanese physician-scientist mentor-mentees viewed more paternalistic mentoring as favourable (Obara et al., 2021).  However, this will need to be individualised, as a highly directive mentoring style may not be well-suited to those who prefer a more collaborative and participatory mentoring relationship. Communication and learning styles may also continue to evolve with as incoming trainee physicians belong increasingly to Generation Z (1997-2012) instead of Generation Y/Millennials (1981-1996). A study of the mentorship experiences of Gen Z women medical students by Li et al (2024) described how current society had afforded them more opportunities for empowerment and expression, and emphasised the importance of tailored mentorship that considered the mentee’s identify and intersectionality.

Having mutual respect and trust were also key. The mentee and mentor having a pre-existing relationship and familiarity helped, and was more common in our context given that mentees could indicate their mentor of interest. Mutual respect and having a personal connection were also identified as key components in effective mentoring relationships by Eller (2014) and Straus (2013).

Whilst we had initially hypothesised that Asian sociocultural concepts would limit mentorship relationships to be largely professional, mentors shared that mutual respect, trust, and time enabled the relationship to also extend to sharing of personal matters and psychosocial wellbeing. Successful relationships were even described as ‘familial’, with a sense of fulfilment from both parties. A family-like relationship and a sense of loyalty to the mentor and organisation was also described in Japanese mentoring relationships (Obara et al., 2021). Such relationships may be more common in more collectivist cultures. These can be furthered by fostering a sense of community amongst mentees and mentors, such as through group activities, peer support, and shared learning experiences.

A. Limitations

This study was conducted in one of the two paediatric training centres in Singapore. Future studies should expand to other postgraduate programs to improve applicability of the results.

The investigators were participants in the program as mentees or mentors, with potential for bias in analysis. To minimise this, transcripts were analysed independently by two investigators followed by review by the third investigator. While our study focused on the lived experience of mentors, examining the perspective of mentees would be able to provide a more balanced and comprehensive understanding of mentoring relationships and highlight gaps where they can be better supported, and should be considered in future studies.

Our study did not delve into gender dynamics. Female medical trainees may face unique challenges, and male mentors may be stereotypically less nurturing and more process-oriented. Existing studies are varied: a survey of American cardiologists found sex concordance to be beneficial (Abudayyeh et al., 2020), whereas Jackson (2003) did not find same-gender matching to be important in an US academic program. In our initial interviews, gender did not come up as a significant factor and was hence not a focus subsequently. The role of gender in our program may have been minimised by a balanced gender ratio, with 59% of faculty female.

B. Future Research and Practical Implications

Given the significant influence of sociocultural factors on mentoring relationships, mentoring programs should be tailored to reflect the unique cultural norms and values of the region. In Asian cultures, this would include methods to reduce hierarchy, ensuring accessibility to mentors, and having a structured program. Training on mentorship for mentors and mentees would be beneficial to promote characteristics of effective mentoring relationships, and should include a focus on culturally sensitive mentoring with a recognition of how culturally-shaped beliefs can affect mentorship. This is particularly important in multicultural societies where cross-cultural mentorship is more common.

V. CONCLUSION

Cultural factors play an important role in shaping mentoring relationships in an Asian context. Whilst such these may be limiting to a degree, these can be also be leveraged on to further effective mentoring programs. Mentoring programs should be tailored to reflect the unique cultural norms and values of the region to promote career growth and personal development of trainees and mentors.

Notes on Contributors

AC, MD and SG contributed to study conception and design. Participant interviews were conducted by AC. Analysis and thematic interpretation were done by AC, MD with review by SG. All authors were involved in drafting the manuscript and reviewing it critically, and all read and approved the final manuscript.

Ethical Approval

The study was approved by the SingHealth Institution Review Board (IRB number 2021/2542).

Data Availability

The data of this qualitative study are not publicly available due to confidentiality agreements with the participants. 

Funding

No funding was received for conducting this study. 

Declaration of Interest

The authors declare that they have no competing interests.  

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*Dr Aletheia Chia
Department of Paediat,
KK Women’s and Children’s Hospital
100 Bukit Timah Road
Singapore 229899
Email: aletheia.chia@mohh.com.sg

Submitted: 8 January 2024
Accepted: 2 July 2024
Published online: 1 October, TAPS 2024, 9(4), 14-25
https://doi.org/10.29060/TAPS.2024-9-4/OA3212

Hema Suryavanshi¹, Santosh R Patil², Kaladhar Reddy Aileni³ & Mohmed Isaqali Karobari⁴

¹Department of Oral Pathology and Microbiology, Chhattisgarh Dental College & Research Institute, India; ²Department of Oral Medicine and Radiology, Chhattisgarh Dental College & Research Institute, India; ³Department of Preventive Dentistry, College of Dentistry, Jouf University, Kingdom of Saudi Arabia; ⁴Dental Research Unit, Centre for Global Health Research, Saveetha Institute of Medical and Technical Sciences, India

Abstract

Introduction: Oral health education is essential for adolescents, yet traditional methods face challenges in engaging this demographic. This study evaluates the effectiveness of a multimedia-based dental education program among high school students. This study was carried out to assess the impact of a comprehensive multimedia-based dental education program on oral health knowledge and practices among high school students.

Methods: A total of 228 students were recruited and randomly assigned to experimental (n=114) and control (n=114) groups. The experimental group received a four-week multimedia program, while the control group followed the standard curriculum. Outcome measures included oral health knowledge scores, brushing frequency, flossing habits, dietary choices, and observational assessments. Statistical analysis employed descriptive statistics, paired t-tests, and analysis of covariance (ANCOVA).

Results: The multimedia-based program led to a significant increase in oral health knowledge scores in the experimental group compared to the control group (Mean Change: 14.6, p < 0.001). Moreover, the experimental group demonstrated higher brushing frequency (p < 0.001), increased flossing habits (p < 0.001), and improved dietary choices (p < 0.05). Observational assessments showed higher adherence to oral hygiene practices in the experimental group (p < 0.001).

Conclusion: The multimedia-based dental education program effectively improved oral health knowledge and practices among high school students. This approach holds promise for scalable and engaging oral health education strategies.

Keywords:           Multimedia-based Education, Oral Health, Adolescents, Dental Education, Health Promotion, Preventive Dentistry

Practice Highlights

• Integrated multimedia elements enhanced participant engagement, utilising videos, e-learning modules, and pamphlets.
• Positive shifts in oral health practices observed, with increased brushing and flossing frequencies in the experimental group.

I. INTRODUCTION

Oral health education serves as a cornerstone in empowering adolescents with the knowledge and skills necessary to maintain optimal oral hygiene. By educating young individuals about the importance of regular brushing, flossing, and dental check-ups, as well as the impact of dietary choices on oral health, preventive practices can be instilled early on. This not only helps in preventing common dental problems like cavities and gum disease but also promotes overall health and quality of life (Nakre & Harikiran, 2013).

Furthermore, addressing oral health education during adolescence is strategic as it provides an opportunity to intervene during a critical developmental stage. By targeting adolescents with effective educational interventions, it becomes possible to shape behavior and instill healthy habits that can last a lifetime. This proactive approach not only benefits the individual’s oral health but also reduces the burden on healthcare systems by minimising the need for costly and invasive dental treatments later in life (Tadin et al., 2022).

The increasing prevalence of dental problems presents a significant public health challenge, as untreated oral diseases can lead to pain, discomfort, and even serious complications such as tooth loss, systemic infections, and impaired overall health (Texas Dental Association, 2008). Moreover, dental problems impose a substantial economic burden on healthcare systems, with costs associated with treatment, emergency care, and lost productivity. In light of these challenges, effective educational interventions are crucial for curbing the burden of oral diseases (Ghoneim et al., 2022). Oral health education programs aim to raise awareness about the importance of oral hygiene, preventive measures, and regular dental check-ups. By providing individuals with the knowledge and skills necessary to maintain good oral health practices, these interventions can empower them to take proactive steps to prevent dental problems and minimise their impact (Kassebaum et al., 2017). This study addresses this need by investigating the impact of a multimedia-based dental education program on the oral health knowledge and practices of high school students.

Adolescence represents a critical period for establishing lifelong health behaviors, and oral health is no exception (National Institutes of Health, 2021). Unfortunately, global studies indicate a concerning prevalence of dental issues among adolescents, including dental caries, gingivitis, and poor oral hygiene practices (Agbelusi & Jeboda., 2006, Zhang et al., 2021). Such issues not only impact immediate health but can also lead to long-term consequences, emphasising the urgency of effective oral health education.

Traditional oral health education methods often face challenges in engaging and effectively conveying information to adolescents. Conventional classroom lectures and textbook-based approaches may struggle to capture the attention of this demographic, potentially limiting the efficacy of such interventions. However, there is evidence to suggest that traditional oral health education has been effective in improving oral health knowledge (Angelopoulou et al., 2015), reducing plaque accumulation, and promoting oral health in adolescents (Gousalya et al., 2022). On the other hand, it is important to note that traditional models of oral health education have been criticised for their didactic delivery and failure to acknowledge the individual context and motivations of the recipients (Ford & Farah., 2012).

As technology becomes increasingly integrated into daily life, leveraging multimedia platforms for health education emerges as a promising strategy to enhance engagement and knowledge retention (George et al., 2014).

The primary objective of this study was to assess the effectiveness of a comprehensive multimedia-based dental education program in improving oral health knowledge and promoting positive oral hygiene practices among high school students. By employing a well-structured intervention and rigorous evaluation, this research aims to contribute valuable insights that can inform the design and implementation of future oral health education initiatives.

The significance of this study lies in its potential to inform evidence-based oral health education strategies for adolescents, especially in regions facing resource constraints. If successful, the multimedia-based approach could serve as a scalable and cost-effective model for widespread implementation in school settings. Ultimately, the outcomes may contribute not only to the improvement of oral health outcomes among adolescents in the study setting but also to the development of best practices with broader implications for global oral health promotion.

II. METHODS

A. Intervention

A comprehensive multimedia-based dental education program was developed by a team of experienced dental educators, multimedia designers, and content developers. The program included visually engaging educational videos covering various aspects of oral health, interactive e-learning modules to reinforce key concepts, and informative pamphlets providing supplementary written material.

Throughout the intervention period, the research team closely monitored the attendance and participation of students in both the experimental and control groups. Attendance records, completion rates of e-learning modules, and participation levels in interactive sessions were meticulously documented to assess the program’s adherence.

1) Program feedback and modification: Continuous feedback sessions were held with both students and educators to evaluate the effectiveness of the multimedia-based dental education program. Adjustments and modifications were made in real-time based on feedback received, ensuring the program remained dynamic and responsive to the specific needs and preferences of the participants.

2) Quality assurance: To maintain consistency and quality across program delivery, educators underwent training sessions, and periodic evaluations were conducted to assess their adherence to the prescribed curriculum and teaching methodologies.

B. Study Design

A randomised controlled trial was conducted involving 228 high school students, aged 14 to 18, recruited from four local high schools in Burhanpur, India, after obtaining permission from the school authorities. Institutional Review Board (IRB) approval with approval number GGSCDS&RC/2022/IEC/168 was obtained prior to the start of this study. Students and their parents/guardians were provided with detailed information about the study, and informed consent was obtained from all participants. The study was conducted between January 2022 and December 2023.

A sample size calculation was conducted prior to the initiation of the study to ensure adequate statistical power. Based on previous literature and anticipated effect sizes, the calculation indicated that a sample size of 228 participants would provide sufficient power to detect significant differences in oral health knowledge and practices between the experimental and control groups. Factors such as an alpha level of 0.05, a power of 0.80, and an effect size estimate derived from similar interventions were taken into consideration during the calculation. This approach ensured that the study was adequately powered to detect meaningful differences in the outcomes of interest.

Random assignment of participants to the experimental and control groups was performed using a computer-generated randomisation sequence. The sequence was generated by an independent researcher not directly involved in the implementation of the study. Participants were assigned to the experimental or control group based on their identification numbers, ensuring an equal chance of allocation to either group. This randomisation process helped minimise selection bias and ensure that any differences observed between the groups could be attributed to the intervention rather than systematic differences in participant characteristics.

Given that participants were recruited from multiple local high schools in Burhanpur, India, cluster randomisation was employed to minimise contamination between groups. High schools were considered as clusters, and randomisation was carried out at the school level to prevent potential contamination of intervention effects between students within the same school. This approach helped maintain the integrity of the study design and reduce the risk of cross-group contamination, thereby enhancing the internal validity of the findings.

To address potential biases related to academic performance, we collected demographic information from all participants, including indicators of academic achievement. This information allowed us to assess any confounding variables during data analysis. Additionally, randomisation was employed to ensure that participants with varying academic backgrounds were equally distributed between the experimental and control groups, minimising the impact of academic performance on study outcomes.

1) Experimental group (n=114): Prior to the intervention, informed consent was obtained from both students and their parents/guardians. The multimedia-based dental education program was delivered to the experimental group during regular school hours. The intervention spanned four weeks, with carefully structured sessions designed to cover topics such as oral anatomy, proper brushing and flossing techniques, the impact of diet on oral health, and the importance of regular dental check-ups. Each week, students participated in interactive discussions, watched educational videos, completed e-learning modules, and received informational pamphlets to reinforce the acquired knowledge. To ensure engagement and understanding, the program incorporated quizzes, group activities, and open discussions facilitated by trained dental educators.

2) Control group (n=114): The control group received the standard oral health education provided as part of the existing school curriculum. The standard curriculum included traditional classroom lectures, textbook readings, and basic demonstrations of oral hygiene practices. No additional multimedia resources were introduced to the control group to maintain a clear distinction from the experimental group.

C. Development of Survey Instrument

The survey instrument utilised for baseline assessment underwent a rigorous validation process to ensure its reliability and validity in measuring participants’ oral health knowledge. The validation process included several key steps aimed at enhancing the quality and accuracy of the survey instrument.

The survey items were delved based on an extensive review of existing literature on oral health knowledge among adolescents. Content experts in the fields of dentistry, public health, and education were consulted to ensure that the survey items adequately covered essential concepts related to oral health.

Prior to the commencement of the main study, a pilot test of the survey instrument was conducted with a small group of high school students similar to the study population. Feedback from the pilot test participants was carefully analysed, and adjustments were made to the wording and clarity of the survey items based on their input.

The survey instrument underwent thorough review by a panel of experts comprising professionals from diverse backgrounds, including dentistry, education, and survey design. The expert panel assessed the relevance, comprehensibility, and appropriateness of the survey items for the target population, providing valuable feedback for further refinement.

D. Outcome Measurements and Analysis

In this study, a comprehensive set of outcome measures was employed to assess the impact of the intervention on participants’ oral health knowledge and practices. The study commenced with a baseline assessment, during which demographic data, oral health history, and participants’ knowledge of oral health practices were collected. Throughout the four-week intervention period, participants’ oral health practices were evaluated weekly through self-reports and observations, ensuring continuous monitoring of their adherence and engagement with the program. Following the intervention, a post-intervention assessment was conducted, and participants’ oral health practices were monitored for an additional two weeks to assess the sustainability of behavior changes beyond the intervention period.

1) Pre-intervention assessment: Before the initiation of the intervention, a thorough baseline assessment of participants’ oral health knowledge was conducted using validated surveys (Appendix A). These surveys covered a wide spectrum of oral health concepts, including the anatomy of teeth and gums, the significance of fluoride, and common dental diseases. Individual knowledge scores were calculated, establishing a baseline measure for each participant, with the maximum score for the knowledge assessment set at 100 (Appendix B).

2) Post-intervention assessment: Following the four-week intervention period, participants from both the experimental and control groups underwent a post-intervention survey (Appendix C). This survey mirrored the pre-intervention assessment and allowed for a direct comparison of changes in knowledge. Individual knowledge scores were recalculated, and the difference between pre- and post-intervention scores was used to quantify the impact of the educational program.

3) Brushing frequency: Participants’ brushing habits were assessed through a combination of self-reporting and observation. Each participant maintained a detailed log, recording the frequency and duration of their toothbrushing activities. Trained researchers also conducted periodic observations to validate self-reported data, enhancing the reliability of the findings.

4) Flossing habits: Similar to brushing, participants self-reported their flossing habits, detailing the frequency and thoroughness of their flossing routine. Periodic checks were conducted to corroborate self-reported data, ensuring the accuracy of the information gathered.

5) Dietary choices: The study assessed participants’ dietary habits related to oral health, including the consumption of sugary snacks and beverages. Dietary logs and self-reporting were used, and nutritional assessments were conducted to evaluate participants’ awareness of the relationship between diet and oral health.

Trained researchers conducted periodic observations to assess participants’ oral health practices in a naturalistic setting. This included direct observations of toothbrushing and flossing routines, as well as an assessment of participants’ adherence to recommended oral hygiene practices.

Throughout the study, continuous monitoring and quality checks were implemented to ensure the accuracy and reliability of the outcome measures. Any deviations or unexpected trends in the data were promptly investigated, and corrective actions were taken as needed. This approach ensured the robustness of the study’s outcome assessments.

Descriptive statistics were employed for demographic data. Paired t-tests were used to compare pre- and post-intervention knowledge scores. Analysis of covariance (ANCOVA) was conducted to assess the impact of the intervention on oral health practices, controlling for baseline differences. IBM SPSS Statistics software (version 22.0) was utilised for data analysis, with a predetermined significance level set at p < 0.05.

III. RESULTS

The demographic characteristics table illustrates a well-balanced study population, with both the experimental and control groups having similar age distributions (16.2 ± 1.0 vs. 16.1 ± 0.9) and gender representation (Male/Female: 56/58 vs. 55/59). Baseline knowledge scores align closely, with mean scores of 45.2 (experimental) and 44.8 (control) and standard deviations of 8.3 and 8.1, respectively (Table 1).

Submitted: 16 December 2022
Accepted: 25 June 2024
Published online: 1 October, TAPS 2024, 9(4), 6-13
https://doi.org/10.29060/TAPS.2024-9-4/OA2928

Pooja Sachdeva & Derrick Chen-Wee Aw

Department of General Medicine, Sengkang General Hospital, Singapore

Abstract

Introduction: Case write-ups and reflective journals have been used as assessment tools of learning in clinical rotations in Yong Loo Lin school of medicine. It is timely to review the current process of conducting these assessments and effectiveness as an assessment tool. This study aims to understand faculty outlook towards these assessments.

Methods: This is a study that involves a survey-based questionnaire with both closed and open-ended questions, sent out to faculty marking the students’ assignments. This survey was anonymous & voluntary and was disseminated by administrative assistants. The purpose of this survey was to collect the feedback from faculty about current process with intentions of improving the effectiveness of these assessments. The suggestions for improvement were incorporated in the survey and faculty was invited to comment over these suggestions and provide further suggestions if any.

Results: Fifty-two responses from faculty were collected and analysed. Ninety percent of respondents thinks that this is an effective tool to assess and promote self-directed learning. Qualitative feedback was received about need of improvement in a) alignment of the submissions timings with rotation postings b) marking rubric to incorporate factors such as case complexity and weightage to different components of case write-ups, c) timely feedback to students, and d) follow up on action plans.

Conclusion: Case write-ups and reflective journals are still effective learning and assessment tools. They promote self-directed learning and clinical analysis in students. Feedback and action plans are the backbone of these assessments and optimal utilisation of these is recommended.

Keywords:           Undergraduate Medical Education, Case Write-ups, Medical Assessments, Reflective Journals

Practice Highlights

• Case write-ups promote critical analysis & clinical judgement and reflection develops metacognition.
• Students should be guided and encouraged to choose cases to promote self-directed learning.
• Marking rubrics need revising and faculty development on how to utilise them.
• Timing of submission needs to be improved to facilitate feedback and follow-up.
• Direct and timely feedback to students and follow up on actions plans improve utility.

Table 1. Comparison of Mini CEX and case write-ups as assessment tools

*For direct feedback, assessor needs to have follow up communication with the student.

**it can be made objective with descriptors provided in the, marking template for each domain that is being assessed.

Evidence has shown that case write-ups do provide assessors the ability to understand students’ learning and analytical skill (McLeod, 1989) and unlike Mini CEX, it involves reflections by students that deepen learning and memory (Fortson & Sisk, 2007). Similarly, Bjerkvik & Hilli (2019) emphasised that reflective journals promote deeper understanding, critical analysis, metacognition and promotes self-development. Onishi (2008) noted that case presentations during clinical rotations promote the assessor’s understanding of student learning which is consistent with our faculty response as most of our faculty (n=47, 90%) agree that case write-ups are important tools to assess learning. However, since these are not observed assessments at the bedside and require submission, there is no face-to-face contact with the student to give instant feedback and discuss action plans, if any. The discussion of feedback and action plan requires separate communication such as a meeting or phone calls or emails between the assessor and student. If appropriate feedback is not provided or communicated, it is a lost opportunity for improvement in students’ learning.

Results from our survey have highlighted a few areas that needed the attention in optimal utilisation of these assessments. First is, the choice of cases, either by faculty or by students is not uniform. The case selection by students promotes self-directed learning. Presently, students are given a list of cases that may help them select one, but the enlisted cases may not be encountered during their rotation. In such situations, faculty suggesting the choice of cases can provide directions to students. Lee et al. (2010) demonstrated that students who were encouraged to choose their cases based on their knowledge gaps, learning strategies, and study time, were more inclined towards self-directed learning. Self-directed learning has been a cornerstone of adult learning, and it provides learners autonomy and control over their learning and prepares them for lifelong self-management outside educational institutions (Goldman, 2009; Lee et al., 2010). Understandably, students’ choice of cases is influenced by the curriculum, tutorials, and objectives of a particular rotation. Case write-ups and Reflective Journals in our context included both inpatient and outpatient encounters hence providing the choice for both acutely sick vs stable chronic patients. Since the students were encouraged to choose their cases for these assessments on their own, it provided them the opportunity to meet their personal goals and learning deficits. However, if asked for guidance, slightly more than half the faculty (56%, n=29) would assign the cases themselves, and of note, such selection of cases, in various forms of frequency and complexity, did affect the marking by faculty by a considerable amount (about 30 to 45%). Nonetheless, the reflective journals involve writing about one’s learning evolution about a case from preset knowledge to acquired knowledge after encounter. Hence, both these written assignments, case write-ups and reflective journals on any encounter tend to improve learning by making students do literature search and individualise this current evidence-based management search in context of the chosen patient. It still serves the purpose of learning, although personal selection of patients encourages students to work on their own interest, at their own pace and promotes deeper understanding tailored to one’s own pre-existing gaps or deficiencies in knowledge. The authors think that faculty assigning cases will inadvertently compromise the extent of self-directed learning to a significant degree and adjusting the marking based on the frequency and complexity is a qualitative component that warrants further investigation. We recommend the school generate a simple set of guidelines to help students to make an informed and wise selection of suitable cases for their written assignments. Focus group discussions with tutors who regularly mark students on such assignments may provide useful directions in the guidelines’ construction.

Results of this survey also raised the inconsistency in faculty use of marking rubrics. McLeod (1989) raised the major concerns about the variability of criteria and standards of evaluation of these written assessments.

Kogan & Shea (2003) addressed these concerns and assessed the evaluation of write-ups against a pre-set evaluation form that increased the validity and reliability of scoring these write ups. Peggy (2014) also highlighted the use of standardised scoring rubric for case write-ups to reduce the interrater variability and improve the reliability of these assessments. Hence, the scoring rubrics must have descriptors for faculty to mark the students against their performances and it not only makes the assessment fair, but also contributes to individualised and appropriate feedback for students for further improvement in respective domains (Cyr et al., 2014; Kogan & Shea, 2005). Thus, the author recommends that universities or schools must emphasise on faculty training and thereby its use in marking these assignments.

This also brought about the feedback, provided by faculty in this survey about components of this rubric. Reflective journals and case reports assess similar yet different components of learning. While case reports accounts more for critical analysis, clinical judgement, evidence-based management for a particular patient, the reflective journals assess the student’s ability to assimilate an encounter with new acquired knowledge and reflect on their individual learning and growth (Sandars, 2009). Hence, rubric should be tailored to these assessments’ subcomponents accordingly. A small fraction of faculty (12%, n=6) in our survey responded that the discussion and analysis of information by students influenced their marking of the write-up as it provided them invaluable insight into students’ clinical reasoning. In line with this, half of the faculty (53%, n=27) recommended that analytic skills be ranked higher in weightage as compared to data collection on patient history and examination. Hence, marking rubric should emphasise more on clinical judgement and critical analysis in case write-ups than components such as history taking and examination as latter can be assessed in detail with other assessments such as Mini CEX or OSCE examinations. At the same time, complexity of the case and atypical presentation must also account for separate marks to encourage students for choosing challenging and difficult cases. Similarly, for reflective journals rubrics must have weightage on self-reflection cycle, changes in attitudes and perception and how the encounters have changed one’s learning and future practice. The role of rubric in standardisation of these written assessments is paramount as former provides a structure of written submissions for students and reliable and valid scoring tool for faculty.

Results of our survey also highlighted pertinent inadequacy in these assessments that is inability to provide the face-to-face feedback to the students in timely fashion, contributed by timing of submissions of these assessments towards the end of rotation. There is ample literature to support that feedback is a backbone of any formative assessment (Clynes & Raftery, 2008; Nicol & Macfarlane‐Dick, 2006) as it promotes self-regulation of training and highlights the discrepancies in the trainee’s current vs expected learning outcome. Hence like every other assessment, the templates of case write-ups are imbued with spaces for feedback and action plans which the majority of faculty (60%, n=31) have personally communicated to the students. Face-to-face feedback has a higher impact on performance improvement than written indirectly communicated or no feedback as the former provides two-way engagement, however, this impact depends upon the supervisor’s training and content & organisation of feedback (Johnson et al., 2020; Pelgrim et al., 2012). The final stage of providing any feedback as per Pendleton’s rule (Pendleton, 1984). Pendleton’s rule is an agreement between the learner and assessor for a joint action plan for improvement. Presently, there is no timeline for students to submit these written assignments to their core supervisor, hence if these are submitted towards the end of the rotation, the opportunity for face-to-face feedback and discussion on action plans is underutilised. Hence, it would be worthwhile to align the submission with weeks of rotation so that timely and personal feedback can be provided and agreed action plans can be followed within the rotation.

This study highlighted that though an action plan was agreed upon, it was not actively followed up with students 90% (n=47) of the time – as such, the accountability of this assessment is reduced. The most common reason for the inability to follow up on action plans was coordination (having to schedule a meeting between the assessor and student when the student may have moved on to the next rotation). This can be modified if students are instructed to submit their assignments at least one or two weeks before the end of posting to allow ample time for both parties to schedule a meet-up. Alternatively, there could be an end-of-posting mandatory meet-up with the clinical supervisor to provide overall feedback for rotation and to discuss action plans. Additionally, the school could also mandate a follow-up meeting, over an interactive online platform if a face-to-face meeting is not feasible, for a supervisor to review the outcomes of the actions undertaken by the student. The school may even consider recruiting student mentors to follow up instead.

Overall, this survey has provided useful insight into these assessments’ conduct and has highlighted the factors that limit the utility of these written assessments. With the faculty agreeing that these assessments are still worthy educational and learning assessment tools, there is a need to improve marking standardisation of these assessments and like other assessments, formative feedback to students on gaps in knowledge must be provided. These assessments have been part of curriculum for decades and their role in students learning must be utilised to its full potential.

There are limitations in our study such as lower number of respondents and qualitative feedback. As survey is voluntary and anonymous, it is limited in its research capability for recommendations and qualitative feedback as latter is respondent dependent. Hence, further qualitative research such as focussed group discussions is required to understand the ways, these assessments can be utilised to their full potential as learning and assessment tools.

VI. CONCLUSION

In conclusion, written assignments are still worthy and useful tools to assess the learning of students during clinical rotations. It promotes self-directed learning by allowing students to select their case and provides the opportunity for the assessor to assess the knowledge gaps of students about case management. Since the case choice affects the marking by the assessor, authors recommend that students are given free reign, within a set of recommended guidelines.

Marking and scoring should be adjusted to include variables such as case selection and complexity in the marking rubric provided to the assessors, hence authors also recommend updating marking rubrics in consultation with faculty, with subsequent faculty development for compulsory use of this rubric.

For these assessments to be more effective, structured, timely and direct feedback should be given to students with action plans that must be followed. The hurdles in following up on action plans such as change of rotations can be dealt with by adjusting the timing of submission of these assessments during a posting and creating opportunities for follow-up. Hence, authors also recommend face-to-face feedback by ensuring adequate timing of assessments and appropriate follow up for action plans to maximise educational improvement opportunities.

Notes on Contributors

Dr. Pooja Sachdeva has contributed to the conceptual development of this study, survey questionnaire development, dissemination of the survey to faculty, data collection, and analysis. This manuscript has been written, read, and finally approved by her.

Dr. Derrick Aw has contributed to the conceptual development of this study, survey questionnaire development, and student and faculty engagement. This manuscript was read, edited, and finally approved by him.

Ethical Approval

The study was approved by the Singhealth Institutional Review Board (IRB) with reference no 2020/2688.

Data Availability

The data that supports the findings of this study are openly available in Figshare repository at https://doi.org/10.6084/m9.figshare.24471661.v1  (Sachdeva & Aw, 2023).

Acknowledgement

We acknowledge the contributions of Dr Shweta Rajkumar Singh for editing the final manuscript.

Funding

There is no funding received for the study.

Declaration of Interest

There are no conflicts of interest.

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*Pooja Sachdeva
110 Sengkang East Way,
Singapore 544886
96170342
Email address: pooja.sachdeva@singhealth.com.sg

Submitted: 3 July 2023
Accepted: 18 June 2024
Published online: 1 October, TAPS 2024, 9(4), 61-64
https://doi.org/10.29060/TAPS.2024-9-4/SC3071

Victoria Scudamore, Sze Yi Beh, Adam Foster & Michaela Goodson

School of Medicine, Newcastle University Medicine Malaysia, Malaysia

Abstract

Introduction: This study compares online and in-person delivery of a weekly clinical reasoning seminar for fourth-year medical students at a Malaysian medical school. During the easing of COVID-19 pandemic restrictions, the initial eight seminars took place online, followed by eleven in-person seminars. This study looks at student preference for online or in-person delivery and how these reasons differ due to gender.

Methods: An online questionnaire was sent to fourth-year medical students after returning to in-person seminars. The response rate was 60/128 (46.88%) and the data was analysed using SPSS software.

Results: 65% of students preferred in-person seminars and a larger proportion of female students (71.43%) preferred in-person sessions compared to male students (50.00%), although this was not statistically significant (p=0.11). A significantly larger proportion of female students preferred in-person seminars for the following reasons compared to male students: enjoyment (p=0.041), developing history-taking skills (55.56%) and for formulating differential diagnoses (p=0.046). Students were asked whether online or in-person seminars were most appropriate for eighteen reasons, they felt in-person seminars were most appropriate for 16/18 of these reasons.

Conclusions: More students preferred in-person clinical reasoning seminars and a higher proportion of these students were female. A significantly larger proportion of female students felt in-person seminars were better for; enjoyment and for developing history-taking skills and formulating differential diagnoses, compared to male students. The students preferred online seminars for home comforts and ease of travel, but they preferred in-person seminars for the other 16/18 reasons listed including all reasons linked to learning skills and interreacting with others.

Keywords:            Online Teaching, In-person Teaching, Gender, Clinical Reasoning, Medical Students

I. INTRODUCTION

Fourth-year medical students at Newcastle Medical School Malaysia attend weekly clinical reasoning seminars as part of their ‘Clinical Decision Making’ (CDM) module. Each week of CDM covers a different medical speciality and students attend a seminar where the group works through a presentation with patient cases and they discuss how to diagnose, investigate and manage the patient. The sessions are attended by eleven students and the groups remain the same throughout the year. In 2021-22 the initial eight seminars took place online using Zoom video conferencing software and as COVID-19 restrictions eased in Malaysia the final eleven sessions took place in-person.

The academic performance of students undertaking online and in-person clinical reasoning seminars has been researched and third-year medical student academic performance was comparable in both settings (Babenko et al., 2022). However, there is currently no research regarding medical student preference for online or in-person delivery of clinical reasoning seminars. Medical student preference for online or in-person delivery of all parts of the curriculum has been analysed and second-year medical students at a US medical school had a preference for online lectures and there was a correlation between these students and those who felt online lectures reduced stress (Altaf et al., 2022).

A cohort study analysed participation in a teaching programme for US graduate physicians and this showed female students asked and answered less questions during in-person sessions compared to online sessions (Cromer et al., 2022). The results of this study are contrasting with my observations whereby female students participated less in online seminars and their participation increased when seminars returned to an in-person setting. This could be due to differences in the research environments or due to the group of observed students being small with less statistical significance.

My first research question was to understand medical student preference and reason for preference of online or in-person delivery of clinical reasoning seminars. My second research question was to establish if student preference differed due to gender and why.

II. METHODS

The data was collected using survey methodology with a self-developed questionnaire made using Microsoft forms. The questionnaire was emailed to all fourth-year medical students after they had experienced both session deliveries. Students were provided with a consent form and informed the research project was optional and were asked to provide voluntary consent before participating. Participants were informed they could withdraw from the project at any time up until the data was anonymised during data collection.

The survey response rate was 60/128 (46.88%), the low participation numbers are likely due to the data collection being optional and undertaken in the students own time. This could lead to a nonresponse bias, as it is likely the more engaged students participated and students with less motivation who did not participate may have responded differently. The data was analysed using SPSS software. Chi-squared tests were used to cross-tabulate the results and to calculate p-values to indicate data with statistical significance.

III. RESULTS

Overall 65% of students preferred in-person seminars and 71.43% (30/42) of female students preferred in-person sessions compared to 50.00% (9/18) of male students (p=0.11). The students were asked if they felt online or in-person seminars were best for eighteen different reasons (see table 1). There were three statistically significant reasons female students preferred in-person sessions more than male students (p<0.05). These were Enjoyment (p=0.041), developing history-taking skills (p=0.011) and formulating differential diagnoses (p=0.046).

The students felt in-person sessions were most appropriate for 16/18 of the reasons listed in (table 1). The reasons with the highest proportion of students feeling in-person were the most appropriate were; interaction with friends (95.00%), interaction with the facilitator (91.67%), and developing clinical reasoning skills (91.67%). There were only two reasons students felt online sessions were most appropriate, these were home comforts (98.33%) and ease of travel (91.67%).

Original data can be accessed in Figshare at https://doi.org/10.6084/m9.figshare.23616627.v1 and https://doi.org/10.6084/m9.figshare.23616630.v1

Results are ranked from reasons with the highest proportion of students thinking in-person was most appropriate for that reason. P-values have been calculated to establish if there is statistical significance between the results for male and female students, significant results are highlighted in bold.

	All students	Female students	Male students	P-value
Interaction with friends	57/60 (95.00%)	39/42 (92.86%)	18/18 (100.00%)	0.245 (>0.05)
Interaction with the facilitator	55/60 (91.67%)	39/42 (92.86%)	16/18 (88.89%)	0.610 (>0.05)
Developing clinical reasoning skills	55/60 (91.67%)	39/42 (92.86%)	16/18 (88.89%)	0.610 (>0.05)
Learning from the facilitator	51/60 (85.00%)	35/42 (83.33%)	16/18 (88.89%)	0.581 (>0.05)
Flow	47/60 (78.33%)	33/42 (78.57%)	14/18 (77.78%)	0.945 (>0.05)
Developing history-taking skills	46/60 (76.67%)	36/42 (85.71%)	10/18 (55.56%)	0.011 (<0.05)
Developing knowledge	45/60 (75.00%)	33/42 (78.57%)	12/18 (66.67%)	0.329 (>0.05)
Ease of sharing opinions	45/60 (75.00%)	33/42 (78.57%)	12/18 (66.67%)	0.329 (>0.05)
Enjoyment	44/60 (73.33%)	34/42 (80.95%)	10/18 (55.56%)	0.041 (<0.05)
Learning from peers	41/60 (68.33%)	28/42 (66.67%)	13/18 (72.22%)	0.672 (>0.05)
Formulating differential diagnoses	41/60 (68.33%)	32/42 (76.19%)	9/18 (50.00%)	0.046 (<0.05)
Interpreting clinical data	40/60 (66.67%)	29/42 (69.05%)	11/18 (61.11%)	0.550 (>0.05)
Formulating management plans	39/60 (65.00%)	29/42 (69.05%)	10/18 (55.56%)	0.315 (>0.05)
Better for mental health	36/60 (60.00%)	26/42 (61.90%)	10/18 (55.56%)	0.645 (>0.05)
Developing communication skills	35/60 (58.33%)	22/42 (52.38%)	13/18 (72.22%)	0.153 (>0.05)
Interpreting investigations	35/60 (58.33%)	27/42 (64.29%)	8/18 (44.44%)	0.153 (>0.05)
Ease of travel	5/60 (8.33%)	5/42 (11.90%)	0/18 (0.00%)	0.126 (>0.05)
Home comforts	1/60 (1.67%)	1/42 (2.38%)	0/18 (0.00%)	0.509 (>0.05)
Table 1. The proportion of medical students who felt in-person sessions were the most appropriate for the listed reasons.

IV. DISCUSSION

Overall, more students in our cohort preferred in-person clinical reasoning seminars and a larger proportion of these students were female than male, however, the difference in preference based on gender did not show statistical significance. This could be due to a smaller cohort of male respondents (18/60) compared to female respondents (42/60). However, even in a study of 488 medical and dental students there was no significant difference in preference for online or in-person delivery when asked about all sessions in the curriculum (Al-Azzam et al., 2020). A larger sample size of medical students will need to be analysed to establish if gender significantly influences student preference for online or in-person delivery of clinical reasoning seminars.

Students felt in-person seminars were better for 16/18 of the listed reasons. This included all reasons pertaining to interaction with other students and staff and all reasons regarding learning a variety of skills. The only two reasons students felt online sessions were better were ease of travel and home comforts. Therefore, this data suggests the only reasons the medical students preferred online seminars were due to the convenience of the setting, and they felt the learning and interaction were superior in in-person seminars.

Of these eighteen reasons, three reasons showed a significant difference in response based on gender, with more female students preferring in-person seminars for the following reasons: enjoyment, development of history-taking skills and formulating differential diagnoses. History-taking and formulating differential diagnoses are more commonly undertaken by doctors within in-person environments. Therefore, female medical students may have a stronger preference for learning skills in the same setting they will be undertaken in when they are doctors.

This study helps to identify the components of clinical reasoning seminars male or female students prefer to undertake online or in-person. Future research could try to identify the reasons for these preferences and to establish if female students have a stronger preference for learning a skill in the same environment it would be undertaken in when they become a doctor.

This research will have most transferability to educators designing clinical reasoning modules to undergraduate students. It may also have some transferability to any undergraduate seminars and to postgraduate medical education. Also, understanding the environment each gender prefers to learn in and why, could help to designing future educational programmes. Especially if these programmes have previously shown differing participation or attainment based on gender.

V. CONCLUSION

In conclusion, students preferred in-person clinical reasoning seminars compared to online seminars and a higher percentage of female students preferred in-person compared to male students, although this was not statistically significant. Students had the strongest preference for in-person sessions due to interaction with friends and the facilitator and for developing clinical skills. Students had the strongest preference for online sessions due to home comforts and ease of travel. Female students preferred in-person seminars compared to male students for the following statistically significant reasons: enjoyment, developing history-taking skills and formulating differential diagnoses.

Notes on Contributors

Dr Victoria Scudamore was involved in data collection, data analysis and wrote this manuscript in full.

Dr Sze Yi Beh was involved in data collection and data analaysis.

Dr Adam Foster was involved in data collection and data analysis.

Dr Michaela Goodson supervised and advised on data collection and analysis.

Ethical Approval

Research and ethics approval was granted by the research committee at Newcastle University Medicine Malaysia on 08/02/2022 (Approval number: 18547/2022).

Data Availability

The data used in this paper is available in the Figshare repository through the following links with associated DOI’s https://doi.org/10.6084/m9.figshare.23616627.v1 and https://doi.org/10.6084/m9.figshare.23616630.v1. The data is shared on the Figshare repository under the CC0 licence (no rights reserved) as there is no copywritten information included.

Funding

No additional funding was used to undertake this project.

Declaration of Interest

There are no potential conflicts of interest to declare.

References

Al-Azzam, N., Elsalem, L., & Gombedza, F. (2020). A cross-sectional study to determine factors affecting dental and medical students’ preference for virtual learning during the COVID-19 outbreak. Heliyon, 6(12), 4. https://doi.org/10.1016/j.heliyon.2020.e05704

Altaf, R., Kling, M., Hough, A., Baig, J., Ball, A., Goldstein, J., Brunworth, J., Chau, C., Dybas, M., & Jacobs, R. J. (2022). The association between distance learning, stress level, and perceived quality of education in medical students after transitioning to a fully online platform. Cureus, 14(4), 3. https://doi.org/10.7759/cureus.24071

Babenko, O., Ding, M., & Lee, A. S. (2022). In-person or online? The effect of delivery mode on team-based learning of clinical reasoning in a family medicine clerkship. Medical Sciences, 10(3), 41. https://doi.org/10.3390/medsci10030041

Cromer, S. J., D’Silva, K. M., Phadke, N. A., Lord, E., Rigotti, N. A., & Baer, H. J. (2022). Gender differences in the amount and type of student participation during in-person and virtual classes in academic medicine learning environments. JAMA Network Open, 5(1), 1. https://doi.org/10.1001/jamanetworkopen.2021.43139

*Dr Victoria Scudamore
Newcastle University Medicine Malaysia
No. 1 Jalan Sarjana 1,
Kota Limu, EduCity@Iskandar,
Iskandar Puteri, Johor, Malaysia, 79200
Email: victoria.scudamore@nhs.net

Submitted: 5 July 2023
Accepted: 12 December 2023
Published online: 2 July, TAPS 2024, 9(3), 1-14
https://doi.org/10.29060/TAPS.2024-9-3/OA3045

Dujeepa D Samarasekera¹, Shuh Shing Lee¹, Su Ping Yeo¹, Julie Chen², Ardi Findyartini^3,4, Nadia Greviana^3,4, Budi Wiweko^3,5, Vishna Devi Nadarajah⁶, Chandramani Thuraisingham⁷, Jen-Hung Yang^8,9, Lawrence Sherman¹⁰

¹Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Department of Family Medicine and Primary Care/ Bau Institute of Medical and Health Sciences Education, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong; ³Medical Education Center, Indonesia Medical Education & Research Institute (IMERI), Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; ⁴Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; ⁵Department of Obstetrics and Gynaecology, Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia;  ⁶IMU Centre of Education and School of Medicine, International Medical University, Kuala Lumpur, Malaysia; ⁷Department of Family Medicine, School of Medicine, International Medical University, Kuala Lumpur, Malaysia; ⁸Medical Education and Humanities Research Center and Institute of Medicine, College of Medicine, Chung Shan Medical University, Taichung, Taiwan; ⁹Department of Dermatology, Chung Shan Medical University Hospital, Taichung, Taiwan; ¹⁰Meducate Global, LLC, Florida, USA

Abstract

Introduction: Continuing medical education and continuing professional development activities (CME/CPD) improve the practice of medical practitioners and allowing them to deliver quality clinical care. However, the systems that oversee CME/CPD as well as the processes around design, delivery, and accreditation vary widely across countries. This study explores the state of CME/CPD in the East and South East Asian region from the perspective of medical practitioners, and makes recommendations for improvement.

Methods: A multi-centre study was conducted across five institutions in Hong Kong, Indonesia, Malaysia, Singapore and Taiwan. The study instrument was a 28-item (27 five-point Likert scale and 1 open-ended items) validated questionnaire that focused on perceptions of the current content, processes and gaps in CME/CPD and further contextualised by educational experts from each participating site. Descriptive analysis was undertaken for quantitative data while the data from open-ended item was categorised into similar categories.

Results: A total of 867 medical practitioners participated in the study. For perceptions on current CME/CPD programme, 75.34% to 88.00% of respondents agreed that CME/CPD increased their skills and competence in providing quality clinical care. For the domain on pharmaceutical industry-supported CME/CPD, the issue of commercial influence was apparent with only 30.24%-56.92% of respondents believing that the CME/CPD in their institution was free from commercial bias. Key areas for improvement for future CME/CPD included 1) content and mode of delivery, 2) independence and funding, 3) administration, 4) location and accessibility and 5) policy and collaboration.

Conclusion: Accessible, practice-relevant content using diverse learning modalities offered by unbiased content providers and subject to transparent and rigorous accreditation processes with minimal administrative hassle are the main considerations for CME/CPD participants.

Keywords:        Medical Education, Health Profession Education, Continuing Professional Development, Continuing Medical Education, Accreditation

Practice Highlights

• Identifying professional practice gaps of clinicians should be the first step.
• The state of CME/CPD varies among countries and addressing relevant needs is crucial.
• Clinicians agreed that CME/CPD improves their skills and knowledge but lacked time to participate.
• Potential improvements include relevant content free from commercial bias and delivery mode.
• Systematic governance and aligned regulations by physician credentialing agencies is recommended.

I. INTRODUCTION

Lifelong learning is an essential skill for all healthcare professionals. This is particularly true when new models of healthcare delivery are being implemented and there is increased focus on outcomes and values such as shorter hospital stay, greater accountability and transparency and emphasis on patient engagement (Sachdeva, 2016; Vinas et al., 2020). Recent literature highlights that continuing medical education and continuing professional development programs (CME/CPD) are crucial in providing current contextually relevant educational and developmental activities in maintaining knowledge, skills, and performance for clinicians and have proven to be effective (Cervero & Gaines, 2015; Drude et al., 2019; Forsetlund et al., 2009). CME is defined as “educational activities which serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public, or the profession” (Accreditation Council for Continuing Medical Education, n.d.), while CPD is usually a broader and more inclusive term referring to the combination of formal CME and other activities type that are designed to assist healthcare professionals to acquire skills and knowledge essential for their professional growth (Sherman & Chappell, 2018). Critical systematic reviews of the literature have shown that CME/CPD improves practice and support professional activities of medical practitioners to deliver best patient care (Cervero & Gaines, 2015; Sachdeva, 2016).

Although CME/CPD has undergone enormous changes and growth over the past 25 years, the advancement in CPD still considerably lag behind as compared to undergraduate and graduate medical education (Sachdeva et al., 2016). Goals and objectives in CME/CPD are often poorly defined and there is a paucity of the curricular structure for medical practitioners (Sachdeva, 2016). Despite consistent evidence sharing that formal CME/CPD activities, such as conferences and workshops, have little or no long-lasting effect on medical practitioners, many CME/CPD providers continue to include these approaches as their major educational offerings while clinicians continue to attend to improve their practice (Mann, 2002). Additionally, there are environments where CME/CPD is not mandatory, and in some instances, non-existent (Sherman & Nishigori, 2020).

Despite CME/CPD’s importance, the state of CME/CPD varies widely across regions and countries. Unlike Europe and the United States, there is no parallel accreditation system for CME/CPD in Asia. CME/CPD does not follow a standard process in all countries and the requirements are also different. A short summary of the CME/CPD system in the countries which are studied in this article is provided in Appendix 1. However, there is still a lack of empirical data in understanding the CME/CPD in Asia. Only one study was conducted in Japan to assess the state of CPD in the country and to identify the gaps in the understanding of the medical practitioners’ needs (Sherman & Nishigori, 2020). Hence, this study aims to explore the state of CME/CPD in the East and South East Asian region from the perspective of medical practitioners, and make recommendations for improvement.

A. Theoretical Framework

Researchers have been proposing few theoretical frameworks which are related to CME/CPD. For this study, we will be using the Process of Change and Learning framework by Fox et al. (1989) to provide an overarching view on the process of change and learning among medical practitioners. This will be further enhanced by using adult learning theory (Knowles, 1989).

No discussion of practice informing theory in CME could exclude the work of Fox et al. (1989), who studied the process of change and learning in the lives of medical practitioners. They interviewed more than 350 medical practitioners to find out the types of learning activities that clinicians undertake and the important factors in the process of learning and change. The framework is illustrated in Figure 1.

Figure 1. Theoretical Framework related to CME/CPD using the process of change and learning (Fox et al., 1989) and adult learning theory (Knowles, 1989)

This framework clearly illustrated how change and learning occurs through several processes and how these changes were influenced by three forces. The actual process of change involves three iterative steps – preparing for the change, making the change, and sustaining or implementing the change in practice.

Through validated studies, we understand that there are three forces to prepare for the change, mainly personal, professional and social forces. Professional forces were found to be the most frequently motivated change. Personal forces, such as the desire for personal well-being, were infrequent and usually not the sole force for change. More often they were combined with professional forces, e.g. the desire to further one’s career. Social forces were also cited, usually combined with professional forces, e.g. relationships with colleagues.

Once the image of change has been developed, medical practitioners will evaluate the discrepancy between what new knowledge and skills are needed to achieve the change and estimate their current capacities. As shown in Figure 1, the perceived discrepancy is positively correlated with the effort that a medical practitioner will put in in learning. Therefore, the next step may involve attending a formal CME event if the discrepancy is high – to understand what is required and to assess or verify one’s own capabilities.

Although the Process of Change and Learning Framework provides us a big picture on how medical practitioners engaged in change and learning, it is insufficient to understand the humanist approach in understanding learning for human growth. It is widely recognised that autonomy and self-directed learning are the developmental nature for human desire to learn (Personal Forces). This behaviour is usually motivated by a mixture of external and internal motivation. This is important for the development of individuals toward autonomy, the self-directed learning, reflective practice and critical reflection, experiential learning, and transformative learning.

II. METHODS

This is a multi-centred study which employed a survey using a validated questionnaire and the section below will describe the data collection process, sampling of participants and data analysis coupled with a qualitative data gathering focus group with educational experts from each place participating. Five sites were involved in this study: Hong Kong, Indonesia, Malaysia, Singapore and Taiwan. Ethical approval was obtained from the respective Institutional Review Board [Reference Number: DSRB-2019-0449 (Singapore), UW 19-840 (HKU/HA HKW IRB) (Hong Kong), KET-1035/UN2.F1/ETIK/PPMetc.00.02/2019 (Indonesia), (CCH-IRB-200425) (Taiwan), IMU 467/2019 (Malaysia)].

The same questionnaire that was used and validated previously in Japan was modified for use in this region (Nishigori and Sherman, 2018). The questionnaire is a self-administered, 28-item test comprising 27 single or multiple-choice questions and an open-ended question for comments. Respondents were asked to rate on a 5-point Likert scale (Strongly Disagree to Strongly Agree) for some of the questions. Demographic questions were included at the start of the survey (e.g. specialty, years of practice, prior participation in CME/CPD activities) followed by the following domains:

• Perceptions and satisfaction of clinicians with regard to current CME/CPD available for them
• Adequacy of the current CME/CPD available
• Impacts of CME/CPD in content coverage, evaluation, and development of learning
• Gaps in CME/CPD
• Future areas to focus on

The items were finalised following a group of experts’ meeting held in Singapore (March 2019) whereby the representatives (medical educationalists and medical practitioners) from participating sites discussed and went through the questions thoroughly. The meeting was moderated by an expert with over 28 years of experience in CME/CPD, and who designed the original study questionnaire. To add more local context and ensure that respondents were able to answer accurately, the questionnaire was translated into the native language and terms by the representatives in some locations.

Medical practitioners were invited to participate in the study.  The study was conducted from July 2019 until May 2020. Voluntary, convenience, and snowball sampling was used and the representatives either disseminate the questionnaire link to their mailing list or through the various national organisation/institutions (Table 1) who then informed their members/faculty, in accordance with the ethics protocol guidelines. Reminders were sent until the response rate no longer increased. Implied consent was obtained from the participants when they proceeded to complete the survey after reading the information about the study on the first page.

Submitted: 2 September 2023
Accepted: 9 January 2024
Published online: 2 July, TAPS 2024, 9(3), 15-21
https://doi.org/10.29060/TAPS.2024-9-3/OA3129

Uzma Khan

Department of Clinical Sciences, College of Medicine, Al Rayan Colleges, Saudi Arabia

Abstract

Objectives: To compare the cut scores and pass/fail rates achieved by arbitrary 60% method and Hofstee method in an undergraduate year 4 end semester objective structured clinical examination (OSCE) and check the possibility of using Hofstee method of standard setting in future exams.

Method: 102 medical students of year 4 underwent a 10 station OSCE exam conducted in a state of art simulation lab in 3 cycles. The cut scores were calculated using arbitrary method aiming at 60% of task achievement and by Hofstee method. The student’s obtained scores were compared for cut scores and pass rates for individual stations and the entire exam.

Results: The arbitrary and Hofstee methods of standard setting leads to different cut scores. For the individual stations it was 60% vs 65-70% and for the overall score it was 60% vs 70%. The percentage of students failing the exam is 13.7% based on arbitrary scores and is 29.4% when Hofstee cut score is applied.

Conclusions: The two methods lead to different cut scores and students’ failure rates. Overall, Hofstee method is more appropriate for assessing competencies in an OSCE exam in medical schools as it leads to calculation of cut scores based on the difficulty level of the station/exam and the examiners expected level of performance by the students.

Keywords:          Objective Structured Clinical Examination, Standard Setting, Hofstee Method, Arbitrary Method

Practice Highlights

• Standard settings of OSCE identifies objective, reliable and valid cutoff scores.
• Arbitrary method scrutinises the test content and nominates the percentage of items to be answered correctly.
• Hofstee method is calculative and avoids illogical very high and low scores.
• A retrospective descriptive study design assessing applicability of Hofstee method in low stake exam in a private medical school in Saudi Arabia.
• Students’ failure rate increased with applying Hofstee standard settings in OSCE.

Figure 1. Calculation of final cut score based on examiners provided four Hofstee values

Arbitrary cut score of 60% is applied to students achieved scores and the pass/fail percentage is calculated and recorded in table 2.

III. RESULTS

The OSCE went on without any significant issues. The data provided by the Exam and evaluation Unit (EEU) according to their software showed that the mean score was 75% with a standard deviation of 3.99% and an alpha coefficient of 1.03. Station wise descriptive results show a range in mean scores from 61 to 84%, illustrating a range in station difficulty. The detailed analysis of each station is shown in table 1.

Table 2. Station wise descriptive statistics, the two cut scores and students pass rates according to cut scores

The mean score for the station reflects its level of difficulty ranging from 61.17% to 83.3%. The cut score of the individual stations for the Hofstee method was higher than the cut score for the arbitrary method. So is the difference in pass rates, pass rates achieved with arbitrary cut scores are higher than with Hofstee method, as shown in Table 3.

Table 3. Comparison of overall cut scores and pass rates

Using Hofstee method and cut of score of 14 out of 20 passing rates achieved is 72 out of 102 which in percentage makes 70.5%. When compared with arbitrary method and cut score of 12 out of 20, students pass rate increased to 88 out of 102 leading to 86% overall. This study points out a higher pass rate for the students by arbitrary method, which creates a doubt on the competency of passing students.

IV. DISCUSSION

In this research, the results of end semester OSCE exam are compared by two methods, arbitrary fixed 60% standard setting method used at our college for the last 4 years and a compromise Hofstee method, which is applied for the very first time.

According to our study, the failure rate has increased from 13.7% to 29.4%, and has almost doubled. In fact, this increase is higher than what had been usually observed previously. This gives the impression that the students who have not yet achieved the required competency would have been allowed to pass. The same observation was made by Dudas et all who did apply Hofstee standard setting to a historic cohort of 116 Johns Hopkins University School of Medicine students from the academic year 2012–2013 to assess the potential impact on grade distributions (Dudas & Barone 2014).

According to the results of a study conducted by Doaa Kamal in Suez Canal University, Egypt in 2020 where four standard methods, the modified Cohen’s, borderline regression, Hofstee methods, and the fixed 60% arbitrary method were compared in determining the passing score in ophthalmology OSCE exam, it was concluded that 60% fixed arbitrary method resulted in a marked difference in failure and pass rates among students and Hofstee method yielded low pass rates which is consistent with my research (Kamal et al., 2020).

Since our exam was dealing with the assessment of multiple competencies, so Hofstee method is more likely to produce a standard appropriate with the purpose of assessment. Secondly the cut scores were calculated by the academic staff who were very much familiar with the OSCE as an assessment tool, the curriculum and the students as well. They were all content experts, fair and open-minded. Some of them were teaching in Taibah university the same content so they were well aware of the acceptable students’ performance. The examiners were meeting the criteria set by Downing et al., so their decision regarding the cut scores and estimation of number of failing students was accepted (Downing et al., 2006).   

Schindler et al in his research paper has applied Hofstee cut off scores and found that it can even be used for a multi assessment surgical clerkship and for assigning grades as well and concluded that this method has all the characteristics of an appropriate standard setting method (Schindler et al., 2007).

V. CONCLUSION

Since different competencies reflect the different level of difficulties, the cut scores need to be set for each station dealing with that competency. The arbitrary 60 % method is not appropriate to the purpose of an OSCE exam, but a cut off score calculated by using data from experts’ judgments provides a reasonable result with acceptable failing rates. Thorough and thoughtful preparation on the judges’ part is deemed important. The data gathered from this exam can be reviewed and acted in accordance with to create a standard each academic year.

Notes on Contributors

The author herself contributed to the design of the research, carried out the data acquisition and analysis, interpreted the data and prepared the manuscript.

Ethical Approval

Approval was obtained from the Institutional Research Ethics Committee (IREC) for the collection and publication of student data with approval No. HA-03-M-122-046. Informed consent is taken from the students and special permission from the dean of the college is obtained for the use of students result for this research purpose.

Data Availability

The data generated and analysed in this study are included in this published article. The raw data set analysed can be provided by the author if special interest in it is shown.

Acknowledgement

I would like to thank Dr. Yasir Naseem Khan from the department of basic medical sciences, Al-Rayan college of medicine for useful suggestions and guidance at the final stage of the project.

I would also like to thank the Dean and the Exam and evaluation Unit (EEU) of the Al-Rayan college of medicine for their support.

Funding

The study does not require any funding.

Declaration of Interest

The author declares that she has no competing interests.

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*Dr. Uzma Khan
Department of Clinical Sciences,
Al Rayan College of Medicine,
Al Rayan National Colleges
Madina Munawara, Saudi Arabia
Contact: +966542754680
Email: uziik2019@gmail.com, uk.yasser@amc.edu.sa