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

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

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

Abstract

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

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

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

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

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

II. METHOD

A. Participants

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

B. Sample Population

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

C. Details of Medical Interview Classes

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

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

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

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

E. Data Analysis

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

III. RESULTS

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

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

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

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

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

Abstract

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

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

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

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

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

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

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

II. METHODS

A. Study Design

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

B. Population and Sampling

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

C. Research Instruments

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

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

D. Data Collection

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

E. Data Analysis

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

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

F. Data Integration

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

III. RESULTS

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

A. Baseline Characteristics

1. Qualitative Sample (n = 20)

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

2. Quantitative Sample (n = 60)

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

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

C. Clinical Outcomes and Programme Effectiveness

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

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

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

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

Abstract

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

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

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

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

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

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

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

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

II. METHODS

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

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

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

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

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

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

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

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

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

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

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

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

III. RESULTS

A. Participants’ Characteristics

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

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

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

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

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

Abstract

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

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

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

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

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

Practice Highlights

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

I. INTRODUCTION

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

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

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

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

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

II. METHODS

A. Context and Setting

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

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

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

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

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

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

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

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

1. Tool Development

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

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

2. Study Participants

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

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

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

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

Abstract

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

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

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

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

Keywords:           Music Preferences, Medical Specialty Selection, Personality Traits

Practice Highlights

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

I. INTRODUCTION

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

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

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

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

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

II. METHODS

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

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

III. RESULTS

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

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

*Kruskal Wallis Test

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

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

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

Figure 2. Proportion of married residents with physician spouse

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

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

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

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

IV. DISCUSSION

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

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

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

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

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

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

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

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

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

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

V. CONCLUSION

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

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

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

Notes on Contributors

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

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

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

Ethical Approval

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

Data Availability

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

Funding

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

Declaration of Interest

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

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Wang, Y., Qu, W., & Ge, Y. (2024). Relationship between personality and music preference: Psychometric adaptation of the music preference scales in a Chinese sample. Musicae Scientiae, 29(1), 109-130. https://doi.org/10.1177/10298649241287072

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

Submitted: 6 November 2024
Accepted: 11 April 2025
Published online: 1 July, TAPS 2025, 10(3), 58-64
https://doi.org/10.29060/TAPS.2025-10-3/OA3567

Nathania Nishida Tan¹, Daniel Ardian Soeselo^2,3, Natalia Puspadewi², V. Dwi Jani Juliawati² & Gisella Anastasia²

¹Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia;  ²Medical Education Unit and ³Department of Surgery, Faculty of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, Indonesia

Abstract

Introduction: Career selection is a critical decision influenced by various factors, including media exposure. As a popular genre among adolescents, medical dramas may shape perceptions of the medical profession. This study explores the impact of medical dramas on medical students’ motivation to pursue a career in medicine.

Methods: This study was conducted at the School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, between February and March 2024, using a mixed-method approach. Quantitative data were gathered through a questionnaire, followed by qualitative insights from in-depth interviews. A two-stage sampling strategy was employed, initially identifying first-year students influenced by medical dramas through screening, followed by purposive sampling to select participants for in-depth interviews.

Results: Analysis identified six key motivational aspects through which medical dramas influence students’ decision to pursue medicine. These include the detailed portrayal of doctors’ roles, their daily lives, and the reinforcement of a positive perception of the profession. Notably, emotional engagement- such as inspiring doctor characters- and the realistic depiction of challenges, including the dedication and hardships of becoming a doctor, emerged as significant factors.

Conclusion: Medical dramas play a significant role in shaping students’ motivation and perception of the medical profession. This study highlights six key motivational aspects influencing career decisions, offering new insights into media-driven career choices and their potential implications for medical education.

Keywords:           Medical Dramas, Medical Education, Medical Students, Student Motivation, Career Choice

Practice Highlights

• Medical dramas serve as informal educational tools through entertainment for the public.
• Television influences adolescents’ career aspirations by shaping their interests.
• Medical dramas shape public perceptions of the medical profession and may inspire viewers.

I. INTRODUCTION

Medical dramas have remained a widely popular television genre since their emergence in the 1960s, continuously evolving to portray healthcare professionals’ professional and personal lives within hospital settings (14^th Media Mutations International Conference, 2023; Sonego & Rocchi, 2024).

Communication theorist Marshall McLuhan had predicted the success of medical dramas as early as 1964 in his book Understanding Media: The Extensions of Man, attributing their appeal to the immersive experience viewers have when witnessing medical procedures, which fosters an “obsession with bodily well-being” (Aboud, 2012; Levine & McLuhan, 1964).

Beyond entertainment, medical dramas serve as informal educational tools illustrating medical practices, bioethical dilemmas, and professional conduct (Cambra-Badii et al., 2021; Zago et al., 2024). Research suggests that these dramas reinforce key principles of medical ethics and professionalism, including communication skills, patient confidentiality, and empathetic bedside manner (Aboud, 2012). By portraying both the challenges and rewards of medical practice, these narratives may also shape viewers’ perceptions of the profession, inspiring people to pursue careers in healthcare (Alahmari, 2023).

Research indicates a correlation between specific television programs and career aspirations, suggesting that the content adolescents consume can shape vocational interests and goals (Gehrau et al., 2016). As an accessible informal educational resource, television provides insight into professional responsibilities and challenges (Mendick & Williams, 2022). Within this context, medical dramas may play a significant role in shaping students’ motivation to enter the medical field. Unlike prior studies that broadly examine media influence over career perceptions, this study focuses on first-year medical students, analysing their motivational drive. By integrating quantitative and qualitative data, this study provides deeper insight into how medical dramas influence medical students’ motivation to pursue a career in medicine.  

II. METHODS

This study was conducted at the School of Medicine and Health Sciences, Atma Jaya Catholic University of Indonesia, from February to March 2024, using a mixed-method approach. A two-stage sampling method was employed, beginning with a questionnaire to identify eligible participants, followed by purposive sampling to select individuals for in-depth interviews. The target population consisted of first-year medical students enrolled in the 2023 academic year who acknowledged that medical dramas had influenced their motivation to pursue a medical degree.

A. Participant Selection

Out of 210 first-year students, 114 reported watching medical dramas. These students completed a demographic questionnaire, which gathered information on gender, parents’ profession, and their viewing habits related to medical dramas. Additionally, they completed the Strength of Motivation for Medical School Revised (SMMS-R) Questionnaire, a validated self-report instrument consisting of 15 items rated on a 5-point Likert scale (ranging from “strongly disagree” to “strongly agree”), with possible scores ranging from 15 to 75, indicating the strength of motivation for medical school.

B. Qualitative Phase Sampling

Purposive sampling was used to ensure an accurate representation of the study population based on key demographic factors, specifically the profession of participants’ parents. The selection process identified respondents from diverse parental backgrounds in the medical field: those with both parents as physicians, those with one parent in medicine, and those with no parental medical background. To ensure gender diversity, one male and one female were selected from each category, all of whom had high motivation scores based on their SMMS-R results. Six participants were selected to achieve thematic saturation, as preliminary analysis showed no new themes emerging beyond this point. Although not statistically representative, this sample captures diverse perspectives on medical career motivation based on different childhood backgrounds.

C. Data Collection

The in-depth interviews, conducted by the researcher (NNT), explored participants’ perceptions of how medical dramas influenced their motivation to pursue a career in medicine. The interview guide addressed various aspects of this influence on their decision-making process. One key question asked was “How have medical dramas influenced your decision to pursue medicine?” All participants provided written informed consent, including permission for audio recording. The interviews were then transcribed verbatim for further analysis.

D. Data Analysis

The transcribed interviews were analysed using thematic analysis with an inductive coding approach, facilitated by Atlas.Ti software. Initial coding was conducted by NNT, who identified key patterns and concepts. These were then systematically categorised into themes and subthemes to capture broader meanings and insights emerging from the interviews. To ensure coding reliability, DAS and NP reviewed the preliminary codes and analysis results. Through thorough discussions and iterative revisions, the team resolved discrepancies and achieved near-total agreement on the coding structure. To maintain participant confidentiality, each transcript was assigned a unique identification code. 

III. RESULTS

A total of 114 respondents participated in this study, consisting of 26 males and 88 females, reflecting a possible gender disparity in medical drama viewership. Among them, 93 students (81.6%) reported that medical dramas significantly impacted their decision to pursue a medical career, while 21 students indicated no such impact.

Characteristic		Respondents (n)	Percentage (%)
Parental Background
	Both parents are doctors	8	7.0
	Only one parent is a doctor	18	15.8
	Neither parent is a doctor	88	77.2
Reports Motivation to Enter Medical Field Due to Medical Dramas
	Yes	93	81.6
	No	21	18.4
	Total Respondents	114	100.0

Table 1. Distribution of Respondent Demographic Characteristics

A. Various Dimensions of the Impact of Medical Dramas on Motivation

The following table presents the themes and subthemes derived from the in-depth interview analysis, which has been discussed and approved by each inter-rater.

No.	Theme	Subtheme
1.	Medical dramas provide an in-depth portrayal of the roles and responsibilities of doctors.	Medical dramas shape public perceptions of the medical profession and doctors’ roles.
		Medical dramas depict the challenges and rewards of doctors’ daily work.
		Medical dramas highlight doctors’ lives beyond their profession.
2.	Medical dramas depict both the professional and personal aspects of doctors’ lives.	Medical dramas reveal lesser-known aspects of doctors’ personal experiences.
		Medical dramas provide an authentic portrayal of doctors’ daily lives.
		Medical dramas depict ethical dilemmas, emphasising doctors’ professional integrity.
3.	Medical dramas contribute to a positive public perception of the medical profession.	Medical dramas portray impressive doctors, evoking admiration, and inspiration in viewers.
		Doctors’ life-saving actions in medical dramas evoke deep emotions and motivation.
		Medical dramas illustrate doctors’ perseverance and resilience in their profession.
		Medical dramas spark curiosity about medical procedures and treatments.
4.	Medical dramas evoke emotional responses that may inspire viewers to pursue a medical career.	Medical dramas evoke empathy by portraying patients in distress.
5.	Medical dramas showcase inspiring doctor characters, motivating viewers to follow in their footsteps.
6.	Medical dramas illustrate the challenges and dedication required to become a doctor.

Table 2. Table of Themes and Subthemes

B. Medical Dramas Provide an In-Depth Portrayal of the Roles and Responsibilities of Doctors

Medical dramas frequently portray various medical scenarios using specialised terminology, offering viewers insight into the daily responsibilities of doctors. As medical settings are generally inaccessible to the public, these dramas provide a unique perspective on the profession. Among the key influences explored in this study, this aspect resonated most with respondents, with four out of six students emphasising its significance.

One participant explained how watching medical dramas sparked their interest in the field, as they previously had limited information about medicine.

“Grey’s Anatomy offered me insight into the medical field and sparked my interest, as reliable information is not easily accessible to those outside the profession” (V1_H3_B19)

Another respondent shared how their perception of doctors shifted from fear to admiration after watching medical dramas, recognising the profession’s vital role in society:

“As a child, I perceived doctors as intimidating due to painful medical visits, such as dental appointments. However, after watching Grey’s Anatomy, I realised that medicine extends beyond that and saw how doctors can positively impact many lives.” (V1_H2_B27)

Beyond hospital settings, medical dramas also depict the role of doctors in broader societal contexts. Through diverse narratives, these dramas offer multiple perspectives on the medical profession. For example, Doc Martin illustrates the role of a doctor in a rural community, showcasing their involvement in local issues, such as water problems and education (V2_H4_B21). This highlights how doctors contribute beyond clinical practice, reinforcing their role in public health and community development.

Additionally, medical dramas influence students’ motivation to pursue medicine by portraying the realities of medical work, including complex procedures and life-saving interventions. More than half of the respondents identified this as a significant factor in their decision to study medicine. As one participant stated:

“The scenes depicting doctors helping others, particularly during surgeries, inspired me to study medicine. I wanted to experience performing surgeries and learn how to help others.” (V4_H7_B19)

These findings suggest that medical dramas not only enhance public understanding of the profession but also play a role in inspiring future medical students.

C. Medical Dramas Depict Both the Professional and Personal Aspects of Doctors’ Lives

Medical dramas depict not only medical procedures but also the personal lives of doctors, including their relationships, friendships, and personal struggles. By presenting doctors as multidimensional individuals beyond their professional roles, these narratives contribute to a more relatable and humanised portrayal of the profession. Notably, four out of six highlighted the importance of this aspect in shaping their motivation. One respondent noted that their interest in medical dramas stemmed primarily from the blend of romantic elements, rather than the medical content alone (V3_H6_B1).

The public often has limited insight into the personal experiences of doctors, making it difficult to relate to them. However, medical dramas help bridge this gap by shedding light on aspects of doctors’ lives that are not commonly shared. This increased visibility fosters a sense of closeness and enhances a deeper understanding of the profession, which may, in turn, inspire career interest. As one participant expressed:

“Medical dramas reveal stories that doctors seldom share, providing an effective way to convey these experiences to the general public.” (V5_H11_B4)

By offering a representation of doctors’ daily lives, medical dramas provide viewers with a deeper understanding of what a career in medicine entails. This additional perspective can be a key factor in the decision-making process for those considering entering the field (V2_H4_B28).

D. Medical Dramas Contribute to a Positive Public Perception of the Medical Profession

Three out of six respondents emphasised that medical dramas portray the ethical dilemmas faced by doctors, reinforcing professional values that shape viewers’ perceptions of the medical field. One respondent noted that the depiction of doctors’ strong work ethic in these dramas increased their interest in pursuing a career in medicine (V3_H6_B4).

Additionally, medical dramas present compelling and admirable doctor characters, which can serve as a source of inspiration for viewers. As one respondent shared:

“The dramatised portrayal made it inspiring for my younger self, leading me to think, ‘Doctors are cool.’” (V5_H11_B2)

The depiction of medical procedures, particularly surgeries, also left a strong impression on some respondents, reinforcing their motivation to enter the medical field. One participant stated:

“Medical dramas provide insight into a doctor’s work, including various surgeries, highlighting the fascinating ability to help many people.”  (V4_H7_B33)

Furthermore, the portrayal of doctors saving lives in medical dramas can evoke strong emotional responses, fostering admiration and a desire to pursue medicine. One respondent expressed how these scenes encouraged them to consider a career in medicine (V5_H11_B2). Medical dramas also emphasise the perseverance and resilience of doctors in the face of various pressures and stress, further reinforcing the appeal of the profession for aspiring medical students (V5_H9_B11).

E. Medical Dramas Evoke Emotional Responses that may Inspire Viewers to Pursue a Medical Career

Medical dramas can spark viewers’ curiosity about medical procedures, motivating them to explore the medical field further and increase their interest in the profession. One respondent noted that medical dramas played a role in their initial motivation for pursuing medicine, as the cases depicted often align with real-world medical scenarios, piquing their interest to learn more:

“I believe the medical procedures shown in Grey’s Anatomy exist in real life and are up to date. For example, an episode featured an abdominal wall transplant, which piqued my curiosity. After researching it, I discovered that the procedure had only recently been developed, showing how the show connects to world medicine.” (V1_H2_B14)

Beyond fostering curiosity, medical dramas also evoke strong emotional responses, such as sadness and empathy, particularly when portraying patients in need of medical care. One respondent shared that such portrayals heightened their awareness of the number of people requiring medical assistance. The emotions they experienced, combined with this awareness, ultimately served as an inspiration to pursue medicine (V1_H2_B31).

F. Medical Dramas Showcase Inspiring Doctor Characters, Motivating Viewers to Follow in their Footsteps

Medical dramas can inspire viewers through uplifting scenes and compelling portrayals of doctor characters. These representations serve as role models, fostering admiration and desire to follow in their footsteps. Notably, three out of six respondents indicated that such portrayals influenced their decision to pursue a medical career. As one participant shared:

“In ‘New Amsterdam’, there is a doctor who stands out from others – someone who wants to create change and has a unique vision. I found him quite inspiring.” (V3_H6_B5)

G. Medical Dramas Illustrate the Challenges and Dedication Required to Become a Doctor

Medical dramas not only portray the professional responsibilities of doctors but also illustrate the journey of becoming one, highlighting the challenges and obstacles along the way. Two out of six students emphasised the significance of this theme, noting that the depiction of medical interns’ experience in these dramas played a crucial role in their motivation to pursue medicine. As one participant shared:

“Medical dramas often depict doctors under immense stress, highlighting the challenges of the profession. However, rather than discouraging me, witnessing their struggles made the career even more appealing.” (V5_H10_B28)

IV. DISCUSSION

The in-depth interviews revealed that medical students felt more mentally prepared and motivated to pursue medicine after watching medical dramas. These shows provided insight into both the professional and personal lives of doctors, reinforcing previous studies on their educational influence in shaping viewers’ perceptions of the medical field. This aligns with the Media Effect Theory, introduced by Gerbner in 1960, which suggests that television shapes individuals’ perceptions of reality, particularly among frequent viewers (Stacks et al., 2015). Hoffman and colleagues further applied this theory to medical dramas, highlighting their role in influencing viewers’ perception of the medical profession (Arias, 2018).

Beyond depicting technical medical procedures, medical dramas also emphasise ethical principles and professional values, contributing to a favourable image of the profession. Research indicates that medical and nursing students often use these shows as supplementary learning tools for bioethics and professionalism (Cambra-Badii et al., 2021). Similarly, these portrayals may inspire high school students to consider careers in medicine by offering an engaging introduction to the field.

Emotional engagement is another key factor in the influence of medical dramas. Strong emotional responses- such as curiosity, empathy, and excitement- can enhance motivation, as emotions play a crucial role in learning, achievement, and psychological well-being, particularly in adolescents (Pekrun, 2017). Positive emotions make tasks more appealing, fostering inner motivation that arises after the initial external excitement provided by medical dramas (Legault, 2016).

Furthermore, medical dramas often depict the challenges of medical training, including long working hours and emotional strain, providing a more nuanced perspective on the profession. While these portrayals may initially present an idealised view of medicine, they also serve as a reality check, reinforcing the dedication required to pursue a medical career. This dual representation may deter less committed individuals while strengthening the resolve of those deeply passionate about the field (Tedeschi, 2024).

However, the potential for misinformation in medical dramas must also be considered. The oversimplifications or dramatisation of medical practice may create discrepancies between fictional portrayals and real-world medicine, leading to misconceptions among viewers (Alismail et al., 2018).  One notable bias is the tendency to depict doctors as infallible heroes performing miraculous saves amidst dramatic emergencies, often intertwined with personal achievements and romantic subplots. This portrayal fosters unrealistic expectations, potentially leading to disillusionment when aspiring medical students encounter the demanding and less glamorous realities of medical education and practice (Tedeschi, 2024).

These findings highlight the complex role of medical dramas in shaping career motivation, offering both inspiration and potential misconceptions. Their influence appears particularly significant for students without a familial background in medicine, as most respondents came from non-medical families. This trend may suggest that medical dramas serve as an accessible source of insight into the profession for those without direct exposure. However, the possibility of sampling bias should be considered, as students already interested in medicine may be more likely to engage in medical dramas. While these dramas may serve as informal educational tools, their impact should be critically assessed to ensure they provide a balanced and realistic portrayal of the medical profession.

V. CONCLUSION

Medical dramas play a significant role in shaping students’ motivation to pursue a medical career by providing an engaging portrayal of the profession. These shows offer insight into the roles and responsibilities of doctors, their daily challenges, and the emotional rewards of the profession. Additionally, they influence public perceptions of medicine and evoke strong emotional responses through inspiring characters and narratives. By depicting both the struggles and triumphs of medical training, medical dramas contribute to students’ understanding of the dedication required to become a doctor. This study highlights six key aspects through which medical dramas impact students’ decision to pursue medical education, highlighting their role as both an informational and motivational tool.

Notes on Contributors

Nathania Nishida Tan participated in data collection, data analysis, review, the writing of the paper, and the formatting for publication.

dr. Daniel Ardian Soeselo, Sp.B, MSi.Med. participated in the data analysis, review, and direction of the paper.

dr. Natalia Puspadewi, M.Med.Ed, Ph.D participated in the data analysis, review, and direction of the paper.

dr. Gisella Anastasia, MHPE participated in the review of the paper.

dr. V. Dwi Jani Juliawati, M.PD, Sp.KKLP participated in the review of the paper.

Ethical Approval

This study received ethical clearance from the Research Ethics Commission of the Faculty of Medicine and Health Sciences Atma Jaya Catholic University of Indonesia under the ethical approval code 13/02/KEP-FKIKUAJ/2024. To ensure confidentiality and data security, all interview transcripts were anonymised and securely stored in password-protected files, accessible only to the research team.

Data Availability

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

Acknowledgement

The authors would like to thank all the students who participated in this study.

Funding

There was no funding for this article.

Declaration of Interest

The authors have no conflicts of interest in connection with this article.

References

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Gehrau, V., Brüggemann, T., & Handrup, J. (2016). Media and occupational aspirations: The effect of television on career aspirations of adolescents. Journal of Broadcasting & Electronic Media, 60(3), 465–483. https://doi.org/10.1080/08838151.2016.1203319

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Zago, D., Cautero, P., Scarpis, E., Pompili, E., Voglino, G., Siliquini, R., Brusaferro, S., & Brunelli, L. (2024). TV medical dramas: Assessing the portrayal of public health in primetime. Frontiers in Public Health, 12. https://doi.org/10.3389/fpubh.2024.1432528

*Daniel Ardian Soeselo
Medical Education Unit and Department of Surgery,
Faculty of Medicine and Health Sciences,
Atma Jaya Catholic University of Indonesia
Jl. Pluit Raya No.2 21, RT.21/RW.8,
Penjaringan, Kec. Penjaringan, Jakarta Utara,
Daerah Khusus Ibukota Jakarta, Indonesia 14440
Email: daniel.ardian@atmajaya.ac.id

Submitted: 16 August 2024
Accepted: 23 December 2024
Published online: 1 July, TAPS 2025, 10(3), 49-57
https://doi.org/10.29060/TAPS.2025-10-3/OA3495

Shuh Shing Lee¹, Shefaly Shorey², Tang Ching Lau³ & Dujeepa D. Samarasekera¹

¹Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Dean’s Office, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Abstract

Introduction: Numerous studies have been conducted on COVID-19, with the majority focusing on interventions involving students and teachers. However, limited research has delved into the pandemic’s impact on the wellness of various stakeholders and how they have adapted to the challenges it presented. This study aims to fill this gap by exploring these neglected areas.

Methods: This study employs a sequential mixed-method approach to study these areas. The quantitative data collection was carried out using a combination of validated surveys (ranging between 63-88 items) for students, faculty and administrators.  Subsequently, qualitative data collection was gathered via semi-structured interview using a convenient sampling method.

Results: Seventeen faculty, 18 administrators and 369 students responded to the survey. The quantitative data indicated faculty (teachers) exhibited the lowest stress levels and the highest resilience during the pandemic. In comparison, administrators and students experienced moderate levels of stress, with students scoring slightly higher on the stress level. The themes that emerged from the qualitative data were personal endurance, emotional reaction, cognitive-behavioural reaction and social support.

Conclusion: Our study highlighted that, apart from personal endurance, the tension arises from emotional and cognitive-behavioural responses of students, teachers, and administrators can be mitigated based on the presence or absence of support mechanisms.

Keywords:           Wellbeing, Change, Stakeholders, Educational Environment, Culture

Practice Highlights

• Students experienced the highest stress levels compared to administrators and teachers.
• However, students and administrators demonstrated resilience, bouncing back quickly after challenging times.
• Students and administrators tolerated for uncertainty and displayed cognitive flexibility to enable them to adapt and seek opportunities.
• Teachers and administrators initially experienced negative emotions, but their emotional resilience facilitated quick recovery.
• Coming from a culture emphasising collectivism, the sense of belonging and social connection served as a protective factor against psychological distress.

Table 1. Sections of the Surveys for Administrators, Teachers and Students

The survey was validated by 10 medical educators from various departments (Paediatrics, Surgery, Centre for Medical Education, Nursing). After the validation, the survey was administered to medical (Year 1 – 5) and nursing (Year 1 – 4) students, administrators and faculty members in Yong Loo Lin School of Medicine and Alice Lee Centre for Nursing Studies using convenient sampling. It took about 20-30 minutes to complete the survey and the data was collected between Jan – June 2021.

B. Phase II Qualitative Data Collection

The qualitative data collection was gathered via semi-structured interview. The interview was conducted for about 60-90 minutes among the medical/nursing students, administrators and faculty members (teachers). Followed up from the data collected from the quantitative data, the questions were revolved around teaching and learning, content, assessment, policies, guidelines, communication, environment (safety)/support and wellness.

From July 2021 – Nov 2022, we used convenient sampling method to recruit of students, administrators and faculty members. The interviews were carried out by 2 trained interviewers with no power relationship with the interviewees. Interviews were carried out after getting consent from the volunteer interviewees. All digital audio recordings made during the interviews were transcribed and member-checked with the interviewees to ensure transparency and trustworthiness of the data.

Data collection ceased when the data reached saturation stage.

C. Data Analysis

The quantitative data was analysed using descriptive statistics (such as mean, frequency and percentage) using Microsoft Excel for the data collected from students, administrators and teachers.

The interviews were thematically analysed by 2 researchers in the team. The two researchers coded the transcripts independently and came together to resolve any discrepancy or disagreement on the coding.  Subsequently, they continued to code and form categories and eventually themes. There were multiple discussions that took place among the researchers and the team before the themes were crystalised.

III. RESULTS

A. Phase I Quantitative Data

The demographic information was illustrated in Table 2. Majority of the participants were not quarantined during the pandemic and more than 80% of them did not have a family member tested positive for COVID when this study was conducted. The teachers from the school of medicine were mainly from Family Medicine, Paediatrics, Physiology, Pathology, Public Health, Medicine, Anatomy and Anaesthesia departments. They are educators for postgraduate and undergraduate students. As for administrators, their roles in the departments are educational related such as instructional design, learning analytics, planning and execution of education, managing project and training.

Table 2. Demographic Information of the Respondents

For each section, the summary was illustrated in Table 3. The mean for different sections was quite close for the 3 groups. Likewise, the items that were scored low and high were quite similar for all the sections. For example, Section B The psychological impact of COVID-19, The sleep quality and concentration in all three groups were not affected by the pandemic, but they are more worries about their family members contracted with COVID-19.

Table 3. Summary of the Mean for Different Sections for the 3 Groups

During the pandemic, students expressed significant concerns about the adequacy of their training, particularly due to reduced patient contact, raising apprehensions about their preparedness for exams. This concern will be elaborated upon in the qualitative data section, shedding light on the depth of their worries. All three groups shared the view that information originating from the government and hospitals was the most reliable, with friends and family scoring the lowest mean among all sources. Despite this, the participants unanimously agreed that the support from friends and family, in terms of both source and level of assistance, was the most substantial. Conversely, organisational support from entities such as the University Wellness Centre, Dean’s office, community, and social media was perceived as unreliable and lacking during the pandemic.

Furthermore, our observations revealed that teachers exhibited the lowest stress levels and the highest resilience during the pandemic, showcasing their ability to cope effectively. In comparison, administrators and students experienced moderate levels of stress, with students scoring slightly higher on the Perceived Stress Scale. Although students acknowledged challenges, as indicated by their agreement with statements such as “I have a hard time making it through stressful events” (mean: 2.93), they also exhibited resilience, agreeing with the statement “I tend to bounce back quickly after hard times” (mean: 3.76). Additionally, concerning self-efficacy towards technology integration, students reported the highest mean score, indicating confidence in their ability to navigate various Internet applications. While teachers felt competent in using technology for teaching and learning, their confidence wavered when it came to resolving technical issues, as reflected in their mean score of 3.47. This nuanced understanding underscores the complex interplay of stress, resilience, and technological proficiency among the different groups during the challenging circumstances of the pandemic.

B. Phase II Qualitative Data

As for the qualitative data collection, we have recruited 7 administrators, 17 teachers (12 from Yong Loo Lin School of Medicine and 5 from Alice Lee Centre for Nursing Studies) and 9 undergraduate students (6 from Yong Loo Lin School of Medicine and 3 from Alice Lee Centre for Nursing Studies). The themes and subthemes that emerged were depicted in the Figure 1.

Figure 1. Themes and Subthemes of the Qualitative Data

1) Theme 1: Personal Endurance

Personal endurance depends on perceived ability and tolerance to uncertainty. For administrators, they felt that it was quite stressful and frustrated during the pandemic as the situation was unclear. However, they were able to manage and there was a sense of relief after they had gone through the critical phase.

“It was very intense, stressful but looking back now, it is not that bad. We have gone through the worse” (Admin 5)

While administrators’ contribution to the education system is crucial, some of the administrators perceived their contribution was minor as compared to medical front liner.

“We are not front liner, our contribution is limited.” (Admin 3)

Although the situation was stressful in the beginning, we noticed a positive endurance among the teachers and perceived the pandemic as an opportunity instead of a threat.

“Overall, I think the predominant mood was of a challenge that needs to be overcome and that brought a certain amount of excitement.” (Teacher 7)

On the other hand, the students felt that they were being too protected and perceived themselves as having the ability to manage the situation themselves.

“I understood that they wanted to protect us but I felt that eventually, they can’t protect us anymore” (Student 3)

The students also perceived that the teachers lacked ability in using technology in teaching and learning especially in remote learning.

“A lot of professors are not familiar with the technology.” (Student 5)

2) Theme 2: Emotional Reaction

There were a lot of negative emotions illustrated by the students, administrators and teachers due to various reasons. Students were worried, frustrated and anxious that they may not learn since the contact with the patients was less during the pandemic. Too much protection from the school and the system put in place has heightened these negative emotions.

“We feel quite unconfident because we feel we have not seen enough patients”/ “..fear that we are not as good as the previous batch” (Students 1 & 2)

Administrators were frustrated mainly because they need to manage the family and work at the same time when working from home system was implemented. However, some of them shared that they are able to regulate and get used to the situation after a while.

“Everybody was under pressure at that time…while I have to juggling with work, my kids were at home because school close.” (Admin 4)

“I usually regulate my own emotion.” (Admin 7)

While there were some positive emotions state in Theme 1 for teachers, they did feel stressful in the early stage of the pandemic due to the change of the approaches in teaching and learning and they are unsure of the outcomes when the teaching was entirely online.

“…stressful in the beginning… I even have nightmares…dreaming students get lost in the virtual room.” (Teacher 17)

“It was a bit stressful in the beginning because you did not know how is going to turn out…” (Teacher 5)

3) Theme 3: Cognitive-Behavioural Reaction

Amidst the challenges posed by the pandemic, administrators, students, and teachers made concerted efforts to adapt their cognition and behavior in response to various initiatives, including social distancing measures, reduced patient contact, and a shift to virtual teaching environments. Throughout this period, interviewees shared both positive and negative reactions to these changes.

Administrators and teachers found themselves navigating the delicate balance between the need to innovate and the need to maintain productivity (ambidexterity). Administrators, in particular, faced the challenge of fostering creativity in coordinating and delivering the curriculum, which involved tasks such as timetabling, resource management, and providing IT support for online learning. These adjustments were made within a short timeframe, reflecting their resilience and adaptability. However, amid these innovative efforts, administrators were also keen on upholding the quality of their work, highlighting the complexity of their role in managing these rapid changes.

“We have to deliver in a short time but also the content has to be rigorous” (Administrator 3)

Similarly, teachers tried to be creative in an online teaching environment and ensure the student learned at the same time especially in small group teaching. However, they find it challenging.

“…there is an urgency to find a way around this small group teaching…we kind of lose the whole power of collaboration.”  (Teacher 5)

There is also a tension arose among the students for being too protected by the school and compromised with their learning as shared in the quotes below. This was repeatedly mentioned by the students, and they felt they have to face the situation eventually.

“I am not very interested in surgery, but this is like once in a lifetime and after I go out of medical school I won’t have the chance to see surgery” (Students 3)

“There’s a culture… in the society in general…protect my child from COVID. But once day we are going to deal with COVID” (Students 6)

Notwithstanding the aforementioned tensions, it’s worth noting that administrators, students, and teachers exhibited remarkable innovativeness and adaptability during the pandemic. All three groups demonstrated evidence of both Operational Capabilities, which encompass the efficient and effective use of resources, and Dynamic Capabilities, which involve the continuous development of competencies to align with the evolving environment.

With the predominant shift in communication from face-to-face to virtual platforms, administrators found themselves assuming the role of intermediaries responsible for conveying information to various stakeholders. In this new virtual setting, where body language cues were less apparent, administrators recognised the need to be more attuned and sensitive to subtle nuances in communication compared to traditional face-to-face interactions. This adaptation reflected their ability to pivot and operate effectively within the changing landscape of remote communication.

“We play the middleman role because we have to speak administrative language to certain people and be sensitive when communicate with faculty members” (Admin 3)

“We have to start thinking about (what kind of information needed) before the faculty member even ask those questions” (Admin 7)

Teachers utilised different resources to innovate in their teaching as well as learning from different others.

“I break it up my lectures into smaller bits and disperse it with PollEverywhere” (Teacher 5)

“We formed a group we called a brown bag meeting – basically we meet at lunchtime with technologically savvy administrators to introduce to the staff on how to make online learning more interactive.”  (Teacher 10)

Likewise, since there was less patient contact time, students tried to make use of their time for other learning sessions.

“Since there’s little time in the hospital, I had read up a lot” (Students 1)

“It allows us to have some processing time and have time to consolidate our knowledge” (Students 5)

4) Theme 4: Social Support Mechanism

Social support mechanism has been mentioned by the 3 groups as one of the prominent mechanisms in adapting the changes during pandemic. It includes transparent communication, team collaboration and support from various stakeholders. For example, administrators shared that they all came together and supported each other during the hard times.

“All different teams come together, I think that was very precious” (Administrator 2)

Students sought seniors’ help to provide additional sessions to compensate their learning.

“What my group would do is we call our seniors to give us extra tutorials” (Student 2)

However, there was also lack of support mechanism brought up by the teachers which led to negative emotion (such as frustration).

“Educational technology team are overworked…if the school would really want to be the best or world class, I think we need a very good support from the IT.” (Teacher 9)

IV. DISCUSSION

The impact of the COVID-19 pandemic on both our educational systems and personal lives has been profound. This unprecedented disruption has been keenly observed by various stakeholders, including administrators, teachers, many of whom were also frontline workers, and students in medical schools. Swift adaptation to the ever-changing situation became imperative, particularly in response to the government’s new guidelines. The abrupt alterations in social interactions and extracurricular activities routines compelled a shift towards a heightened emphasis on family life, accompanied by the necessity to work and learn from home due to lockdown measures. These changes had profound physical and psychological effects on our lives.

Our study revealed that students experienced the highest stress levels compared to administrators and teachers, a finding consistent with previous research indicating that medical students often have higher baseline anxiety than their peers studying other disciplines (Dyrbye et al., 2006; Lasheras et al., 2020). Qualitative data highlighted that students’ stress levels were primarily attributed to the lack of patient contact and inadequate training, potentially impacting their future practice. Additionally, students expressed feelings overly protected due to initiatives like stay-at-home learning. The altered learning environment, combined with a lack of guidance on learning strategies and interpersonal relationships, left students vulnerable to intense emotional fluctuations and strained family relationships (Zhang et al., 2020). Similarly, for administrators, the shift to remote work and social isolation policies posed challenges in balancing work and family responsibilities, as evident from their qualitative comments.

However, students and administrators demonstrated resilience, bouncing back quickly after challenging times. According to Del Carmen Pérez Fuentes et al.’s (2020) Adaptability to Change framework, a sense of control, tolerance for uncertainty, and cognitive flexibility are crucial in coping with adverse situations. Despite feeling anxious and frustrated due to the inability to control the study-from-home or working-from-home policy, student and administrator tolerated for uncertainty and display cognitive flexibility to enable them to adapt and seek opportunities. Emotional resilience, the ability to generate positive emotions and recover swiftly from negative emotional experiences, played a pivotal role in psychological resilience (Zhang et al., 2020). This emotional resilience led to diverse emotional responses, influencing the cognitive processing of emotional information. Teachers and administrators initially experienced negative emotions, but their emotional resilience facilitated quick recovery, evident from their transcripts.

Emotional and cognitive-behavioural responses were further shaped by social support mechanisms within peer groups, colleagues, organisational leaders, and the government. While studies have shown that social media can heighten anxiety due to misinformation and distressing news (Gao et al., 2020), our research indicated that students, teachers, and administrators placed significant trust in information provided by the government and institutions. This trust in government intentions and capabilities fosters adherence to health regulations, essential in crisis management (Siegrist & Zingg, 2014).

Coming from a culture emphasising collectivism, our society values interdependence and family connections highly. This sense of belonging and social connection served as a protective factor against psychological distress, aligning with previous research findings (Xiao, 2021; Yu et al., 2020) . Conversely, a lack of social support within a collectivist culture, as reported by teachers and students, contributed to psychological distress. Our qualitative and quantitative data in this study support this observation, emphasising the significance of social support structures in mitigating the adverse effects of challenging circumstances. The importance of fostering a supportive environment, both within institutions and at a societal level, cannot be overstated in times of crisis.

V. LIMITATIONS

This study has some potential limitations. The study was carried out in a single medical school; hence, the results can only be transferable to the same context. The number of respondents was quite small (especially for nursing respondents) despite multiple reminders sent to the various groups. Therefore, they may not be representative of the entire student, teachers and administrator’s population. Third, the survey was a self-reported survey and may have inherent biases while answering the questions. While rigor is more challenging to achieve in qualitative data collection and analysis, the researchers adhere to the trustworthiness principles as much as possible in analysing and presenting the results in this paper.

VI. CONCLUSION

In conclusion, achieving wellness during a pandemic is indeed possible, but it hinges not only on the resources that organisations and governments can marshal but also on individual resilience in navigating uncertainty, cultural factors, trust, and support systems. Our study highlights the importance of familial and peer connections within our cultural context, underscoring how these bonds facilitate adaptation and innovation amid the challenges posed by the pandemic. The emotional and cognitive-behavioural responses of students, teachers, and administrators are depending on their personal endurance. However, the tension that arises in these individuals can be mitigated or exacerbated based on the presence or absence of adequate support mechanisms. Sufficient support can act as a buffer, helping individuals cope effectively with the challenges they face. Conversely, insufficient support can exacerbate stress and strain, hindering their ability to adapt and respond positively to the situation at hand.

Therefore, fostering a strong support network, both within organisations and communities, is crucial. This support not only alleviates the immediate challenges faced by individuals but also empowers them to build emotional resilience, enabling them to navigate uncertainties and adversities with greater ease. In this way, the collective endurance of individuals, coupled with robust support systems, becomes the cornerstone of achieving wellness and fostering positive responses in the face of a pandemic.

Notes on Contributors

DDS developed the research idea and design with SSL, SR & LTC. The data collection was performed by SSL. The data were analysed by SSL & DDS. DDS, SSL, SR & LTC performed the data interpretation. DDS, SSL & SR wrote the article with revision by LTC. All the authors read and agreed with the final manuscript.

Ethical Approval

Ethics approval was sought from the National University of Singapore (NUS) Institutional Review Board (NUS-IRB-2020-216). Written informed consent was obtained from all participants.

Data Availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available as the participants of this study did not give written consent for their data to be shared publicly.

Acknowledgement

We would like to express our heartfelt gratitude to Jillian Yeo and Lilusha Kaludewa for helping in data collection and analysis.

Funding

No funding is available for this research.

Declaration of Interest

The authors report that there are no conflict of interests to declare.

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*Lee Shuh Shing
Centre for Medical Education,
Yong Loo Lin School of Medicine,
National University of Singapore, Singapore
10 Medical Dr, Singapore 117597
Email: medlss@nus.edu.sg

Submitted: 31 July 2024
Accepted: 24 February 2025
Published online: 1 July, TAPS 2025, 10(3), 37-48
https://doi.org/10.29060/TAPS.2025-10-3/OA3473

Kevin Xuan Hong Tang¹, Koon Kee Teo¹ & Kye Mon Min Swe²

¹Department of Medicine, Faculty of Medicine, Newcastle University Medicine Malaysia (NUMed), Malaysia; ²Department of Research, Faculty of Medicine, Newcastle University Medicine Malaysia (NUMed), Malaysia

Abstract

Introduction: Every medical graduate is expected to fulfil the teaching responsibilities stated by the General Medical Council (GMC). It is beneficial to nurture both teaching motivation and skills early in the undergraduate program. This study aims to evaluate the outcomes of final-year medical students as near-peer teachers in a student-led near-peer teaching program and their fulfilment of the educational responsibilities stated by the GMC.

Methods: A cross-sectional study was conducted among the year 5 medical students who participated in the Peer Teaching Program. A structured post-participation 6-point Likert scale questionnaire with written consent was distributed to the near-peer teachers to assess their perspectives on skills enhancement, motivation, and career direction. Additionally, the Peer Tutor Assessment Instrument questionnaires were distributed to the near-peer students to evaluate the performance of the near-peer teachers in five areas: responsibility and respect, information processing, communication, critical analysis, and self-awareness.

Results: There were 28 near-peer teachers, and 49 near-peer students participated in the study.  The near-peer teachers score the highest in skills (5.36 ± 0.53), followed by motivation (5.16 ± 0.60) and career direction (4.79 ± 0.82). Three quarters of the near-peer teachers considered teaching to be their future primary career path after experiencing this teaching experience (4.36 ±1.34). Generally, the near-peer teachers were highly evaluated by the near-peer students across all domains (5.06 ± 0.51).

Conclusion: Overall, the near-peer teaching programme likely improved the final-year medical students in fulfilling the “Doctors as Teachers” responsibilities outlined by the GMC.

Keywords:           Near-peer Teaching, Medical Students, Undergraduate Medical Education, General Medical Council, Doctors as Teachers

Practice Highlights

• Near-peer teachers are likely improved in skills enhancement, motivation and career direction.
• Sex and students’ background are not associated with the perceived outcomes of near-peer teachers.

I. INTRODUCTION

One of the aspects of Good Medical Practice outlined by the General Medical Council (GMC) for all medical professionals is to “be willing to offer professional support to colleagues, including students, through teaching” (General Medical Council, 2023). The role of doctors as teachers has been widely recognised as they need to teach and educate juniors, students and even patients (General Medical Council, 2011, 2015, 2023). On average, junior doctors spend around 80 minutes per day teaching medical students (Busari et al., 2002). This task is daunting for every new medical graduate who has just begun their UK foundation programme. They need to assume this responsibility with minimal formal training and preparations (Pierce et al., 2024; Qureshi et al., 2013).

Therefore, it is beneficial to motivate medical graduates to teach and equip them with appropriate teaching skills as early as their undergraduate programme (General Medical Council, 2011; Knobloch et al., 2018). Near-peer teaching involves students one or more academic years ahead teaching their peers or junior students (De Menezes & Premnath, 2016; Ten Cate & Durning, 2007; Yu et al., 2011). This has long been thought of as a programme to be incorporated into the medical curriculum to optimise teaching qualities and to produce more competent and knowledgeable doctors in the future (Botelho et al., 2022; Burgess et al., 2014; Zheng & Wang, 2022). Generally, medical schools provide a safe space for medical students to practice, correct and improve their teaching and pedagogical skills (Hardie et al., 2022). Most medical students feel less daunted and more supported involved in teaching their near-peer students (Yu et al., 2011).

To address this gap of insufficient teaching opportunities, most medical schools provide near-peer teaching programmes for their medical student (Frearson & Gale, 2017). However, most of the near-peer teaching programmes are carried out formally with structured guidance and training (General Medical Council, 2011), be it in the form of the Peer Assisted Learning Scheme (PALS) student-selected components (SSC) (Furmedge et al., 2014; Hettle & Morgan, 2019; Ross & Cameron, 2007; Ten Cate & Durning, 2007) or Doctors as Teachers and Educators training course (Cook et al., 2010; General Medical Council, 2011). Little is known about the outcomes of the student-led, student-run, near-peer teaching (NPT) programme in medical schools.

In the academic year 2023/2024, the Newcastle University Medicine Malaysia (NUMed) final-year medical students were involved as near-pear teachers in an NPT programme. This study thus aims to evaluate the outcomes of participation of the final year medical students as near-peer teachers in the student-led near-peer teaching programme and to determine whether the soon-to-be medical graduates can fulfil the “Doctors as Teachers” responsibilities stated by the GMC.  

II. METHODS

The NPT Programme was a purely student-led, student-run 3-month teaching programme which provided additional focus on the learning outcomes of the third-year medical curriculum. This programme functioned as an adjunct to the formal curriculum and provided precious opportunities for final-year medical students to improve their teaching skills.

Before the academic year started, invitation email was sent out to recruit final-year medical students to participate voluntarily as the near-peer teachers and the year 3 medical students as the near-peer students. A total of 51 final-year medical students and 100 year 3 medical students signed up for this programme. The near-peer students were randomly assigned to groups of 5 to 6 each, and each group was guided by 3 near-peer teachers. Before the programme commenced, all near-peer teachers were required to attend a mandatory online training course conducted by the lecturers to enhance their presentation and teaching skills.

This programme comprised a total of twelve teaching sessions spanning twelve weeks, covering four sessions of Essential Clinical Placement teaching sessions, four sessions of Case-Based Discussion, one surgical teaching topic and case-based session, one Single Best Answer practice session, one Written Prescribing Exam (WRISKE) session and one Objective Structural Clinical Examination (OSCE) session. Most sessions were delivered virtually (Zoom) or physically, depending on students’ preferences, except for the OSCE session, which was always conducted physically. The teaching materials were prepared by the near-peer teachers beforehand and distributed to the students after each teaching session. The NPT programme coordinator supervised and provided necessary support to both near-peer teachers and near-peer students throughout the entire programme.

The near-peer teachers and near-peer students consented to participate in this study via written consent. A structured post-participation Likert 6-point scale “Peer Tutors Own Assessment” questionnaire with written consent, which was adopted from Liew et al. (2015), was sent to the near-peer teachers after this Near-Peer Teaching Programme via Google form to explore their perceived benefits in three components which are 1) Skills Enhancement, 2) Motivation and 3) Career Direction [Expectation]. This questionnaire (Appendix 1) contains 14 items, with responses scale from strongly disagree (1) to strongly agree (6). Cronbach’s alpha was 0.801, 0.714, and 0.814 for the domains of skills enhancement, motivation, and career direction.

Similarly, all the near-peer students who participated in this near-peer teaching programme were given the Peer Tutor Assessment questionnaire adopted from Liew et al. (2015), to fill in via Google form (Appendix 2). This questionnaire is to assess the acceptability of the teachings of the near-peer teachers. It contains 16 items that evaluate five domains: (1) Responsibility and Respect, (2) Information Processing, (3) Communication, (4) Critical Analysis, and (5) Self-Awareness. Subgroup analyses were conducted to evaluate whether sex and student background affect self-perceived outcomes of near-peer teachers using independent T-test. Each participant was given 3 weeks to complete the questionnaire. Several reminders were sent via email throughout these 3 weeks to each participant to encourage them to fill in the questionnaire. Both near-peer teachers and near-peer students’ data were checked for normality. The asymmetry fell between -1 and +1 and assumed relatively symmetrical and mesokurtic.

III. RESULTS

A total of 51 medical students in their final year signed up as near-peer teachers. Of these, 28 near-peer teachers completed the questionnaire (response rate 54.9%), while 49 out of 100 near-peer students who joined this NPT programme responded in this study (response rate 49.0%). Among those near-peer teachers who responded, there were 9 (32.1%) males and 19 (67.9%) females. More local students responded in this study than international students (75% vs 25%). The overall mean age ± SD of the near-peer teachers is 23.75 ±1.21 years old.  For the near-peer students, the overall mean age ± SD is 21.69 ± 0.74 years old. The number of international and local near-peer students who responded was similar. The data of the responses of both near-peer teachers and near-peer students that supports the findings of this study  is openly available at Figshare https://doi.org/10.6084/m9.figshare.26886517.v1 (Tang et al., 2024a) and https://doi.org/10.6084/m9.figshare.26886514.v1 (Tang et al., 2024b).

Table 1 showed peer review findings to ensure their voices were represented. To ensure the trustworthiness of the findings, actions were taken to address credibility, dependability, confirmability, transferability, and reflexitivity are outlined in Table 2. Figure 1 indicates the near-peer teachers view of the benefits of involving in the student-led near-peer teaching program.

Table 1. Demographic data of the near-peer teachers

Table 2. The mean score (± SD) for the self-evaluation of near-peer teachers in relation to (1) skills enhancement, (2) motivation and (3) career direction (expectation)

Figure 1. Near-peer teachers view of the benefits of involving in the student-led NPT program: Analysis of post-participation questions responses (n=28) in Likert 6-point scale in relation to (a) skills enhancement, (b) motivation and (c) career direction (expectation)

Based on the responses to the questionnaire, the near-pear teachers widely agreed that the NPT programme positively impacted them (5.11 ± 0.58), with the highest score in the domain of skills enhancement (5.36 ± 0.53), followed by motivation (5.16 ± 0.60) and career direction (4.79 ± 0.82). Most of the near-peer teachers considered this programme improved their skills in terms of teaching, organising, communicating and understanding educational principles (Table 2). 100% of them agreed that this NPT programme increased their confidence in speaking to groups and enhanced their planning and organising skills.  Furthermore, all 28 respondents (100%) reported being more motivated to revise their own clinical skills and focus more on their practical skills after teaching near-peer students to address the

knowledge gap. A significant proportion of near-peer teachers felt more encouraged to participate in more teaching programmes in the future (n=27, 96.43%) and more inclined to help fellow students next time (n=25, 89.28%).  It is noteworthy that 96.43% of near-peer teachers agreeing that this NPT programme helped in deciding their career direction and motivated them to undertake more trainings. Besides, three quarters of them would consider teaching as their major career pathway in the future, with a mean score of 4.36 ± 1.34. Lastly, all 28 respondents (100%) agreed that joining the NPT programme had enhanced their curriculum vitae (100%).

Table 3 shows the mean score of near-peer students’ evaluation of near-peer teachers in five domains after joining the near-peer teaching programme.

Table 3. The mean score (± SD) for the near-peer students’ evaluation of near-peer teachers after the NPT programme in relation to (1) responsibility and respect, (2) information processing, (3) communication, (4) critical analysis and (5) self-awareness

When asked to evaluate the teaching of their near-peer teachers, the near-peer students considered the near-peer teachers demonstrating positive outcomes in all five domains (5.06 ± 0.51). The near-peer teachers were thought to have a high degree of professionalism in terms of responsibility and respect (5.15 ± 0.57) and self-awareness (5.11 ± 0.62). The most outstanding attribute demonstrated was the ability to complete assigned tasks appropriately (5.27 ± 0.73). Besides, the near-peer teachers performed satisfactorily to process information (5.12± 0.66), communicate (5.01± 0.65) and analyse critically (4.93 ± 0.66). However, the near-peer teachers were identified to score slightly lower in making non-confusing comments and responses (4.92 ± 0.84) as well as giving a summary of the session (4.90 ± 0.82).

Variables	Independent T- test
	Mean difference (95% CI)	P-value
Sex (Male vs Female)
Skills	-0.101 (-0.549, 0.348)	0.649
Motivation	0.118 (-0.385, 0.621)	0.634
Career Direction (Expectation)	0.507 (-0.154, 1.169)	0.127
Students’ background (Local vs International)
Skills	-0.210 (-0.688, 0.268)	0.376
Motivation	-0.276 (-0.810, 0.258)	0.297
Career Direction (Expectation)	0.280 (-0.439, 1.034)	0.414

Table 4. Comparison of self-perceived outcomes of near-peer teachers between male and female, local and international students (Independent t-test)

The independent t-test were performed to find out the association between sex and perceived outcomes of the near-peer teachers. Our study revealed that it is statistically insignificant between male and female in the perceived benefits for skills (P = 0.649), motivation (P = 0.549) and career direction (P = 0.127).

Besides, there is no correlation between students’ background and the three measured outcomes. There is statistically insignificant between local and international students in term of skills (P = 0.376), motivation (P = 0.397) and career direction (P = 0.414).

IV. DISCUSSION

This study provides valuable insights into the background and characteristics of the final-year medical students who voluntarily participated in a student-led, student-run NPT programme. The outcomes of their participation concerning their perceived benefits in terms of skills, motivation, and expectations were investigated. Overall, the near-peer teachers reported that this NPT programme helped them tremendously to improve their skills in terms of learning and teaching, which might be driven by their primary motive for joining this programme. This finding was similar to previous studies, which showed skills enhancement in volunteer near-peer teachers (Buckley & Zamora, 2007; Liew et al., 2015). Our study further reaffirms the plausibility of a student-run NPT programme to enhance teaching and learning skills. However, due to the voluntary nature of participation in this near-peer teaching programme, the students who are likely most in need of skill enhancement may have been omitted from this programme, and they might be less equipped to teach after they graduate. Some studies recommended more incentives to be given to such students to encourage them to make use of the opportunities offered (Buckley & Zamora, 2007).

The motivation evaluated includes both self-actualising inner motivations to improve their clinical and practical skills and the external, tangible desire to help fellow students. The high motivation score suggests the reinforcement of a desirable attitude towards future educational and teaching responsibilities, which matches the GMC’s emphasis on the teaching role of doctors (General Medical Council, 2015). A couple of reasons may explain this: firstly, the near-peer teachers are final-year medical students, who will sit for their final examinations very soon and are desperately finding ways to improve their learning. The process of teaching, which requires extensive preparation, a comprehensive understanding of the content, dynamic synthesis, and anticipation of the questions that may be asked of them, forms an efficient learning strategy. Secondly, the near-peer teachers, inspired by the excellent teaching they once had, wish to impart good teaching to the near-peer students going through the same journey.

Although many near-peer teachers are more motivated to be involved in more teaching and even take up teaching training courses in the future, the influence is not apparent in the long-term career direction. This could be explained well by the brief intervention of this NPT programme that lasted 3 months. However, the lucrative income opportunities in other medical specialities and the limited exposure to medical education pathways in undergraduate medical schools are some factors that may sway them away from considering medical education as their primary career pathway (Puri et al., 2021; Sarikhani et al., 2021). Therefore, more effort should be directed to increase teaching opportunities and to raise awareness of medical education career options in the undergraduate medical school programme. This includes developing Student Selected Components focusing on medical education and giving opportunities to shadow clinical teaching staff (Liew et al., 2015; Wilson et al., 2008).

After participating in this study, the near-peer students evaluated the near-peer teachers highly in all the domains. This provides a strong indication of the recognition and acceptance of the teaching skills of the near-peer teachers. In addition, the ability of the near-peer teachers to demonstrate responsibility and respect throughout this programme shows their preparedness to work under the GMC with desirable attitudes and professionalism. Previous studies have also shown that near-peer teachers gain more subjectively and objectively than students (Liew et al., 2015; Ten Cate & Durning, 2007). This can be related to the underpinning of the psychological and social theories behind the dynamics between near-peer teachers and near-peer students (Loda et al., 2019). The theoretical model of cognitive and social congruence explains the positive evaluation of the near-peer teachers (Loda et al., 2019; Rollmann et al., 2023). The proximity of age between the near-peer teachers and the near-peer students enables them to share similar knowledge frameworks, language and social roles.  Besides, near-peer teachers are perceived to be more approachable and understanding of the needs and struggles of the near-peer students. This may be because the near-peer teachers have had similar experiences themselves. Therefore, near-peer teachers are better able to process difficult concepts and frameworks, emphasize the key points, and communicate the information using familiar and non-confusing language to ensure that near-peer students comprehend better (Loda et al., 2019; Loda et al., 2020). The perceived barrier to providing feedback to near-peer teachers is also lower compared to faculty-led staff, as the age difference between them is much smaller. This might suggest why near-peer teachers feel less offended by criticism and are more likely to accept and respond to criticism gracefully (Loda et al., 2019). Nevertheless, the near-peer students thought that some near-peer teachers experienced some difficulties in giving relevant input and summary of the sessions, thus necessitating more structured pedagogical training for near-peer teachers in this aspect. Mastering these teaching skills would allow the near-peer students to appreciate better the big picture and key takeaway points of each lesson (Khaw & Raw, 2016).

One of the focuses of this study is to analyse the sex-specific difference of the perceived outcomes of the near-peer teachers. Although there is an appropriate twice female near-peer teachers who responded to this study compared to male near-peer teachers, the results shows that the sex-specific difference in the perceived improvement in motivation, skills and career direction is not significant. There is no sex-specific difference in term of enthusiasm and motivation to involve in near-peer teaching (Messerer et al., 2021).  Throughout the whole process, they receive similar gender-equitable support and guidance without any discrimination.

V. LIMITATIONS AND RECOMMENDATIONS

As few studies have reported outcomes for a purely student-led student-run NPT programme, this study offers valuable insights concerning the perceived benefits for near-peer teachers. However, this study has several limitations. Firstly, given the relatively small sample size of the near-peer teachers and the subjective nature of the self-reported questionnaire, the results may benefit from further objective testing, such as correlation with examination results. Secondly, this study is only carried out in a single medical school, with a slight variation in the implementation of the NPT compared to other institutions. Verification of these results across various medical schools would strengthen these findings. This study thus calls for more structured student-led peer teaching programmes to be implemented in more medical schools and to be assessed longitudinally to evaluate the association between the student-led peer teaching programme and the outcomes of participation of the near-peer teachers. It may also be worthwhile to investigate and assess the perspective of near-pear teachers who demonstrated interest in medical education, as well as to evaluate the long-term outcomes in career direction for medical graduates who once participated in near-peer teaching programmes.

VI. CONCLUSION

In conclusion, this purely student-led, student-run near-peer teaching programme likely improved the final-year medical students in fulfilling the “Doctors as Teachers” responsibilities outlined by the GMC. Besides, the near-peer teachers also reported having positive outcomes in their skills and career direction.  Likewise, from the perspective of the near-peer students, the near-peer teachers demonstrated outstanding skills and professionalism in all five domains: responsibility and respect, information processing, communication, critical analysis and self-awareness. Possessing the skills and professionalism fulfils the expectations of GMC for healthcare professionals to provide the right care at the right time with the right skills for the good of patients.

Notes on Contributors

Kevin Xuan Hong Tang was a final year medical student who conceptualised and designed the study, reviwed the literature, conducted the data collection and analysis, prepared the figures and wrote the manuscript.

Koon Kee Teo was a final year medical student who reviewed the literature, collected and analysed the data, prepared the figures and helped in writing the manuscript.

Kye Mon Min Swe is an Associate Professor in Education Research in NUMed. She participated in conceptualising the study, performed statistical analysis and drafted, reviewed and edited the manuscript. All the authors have read and approved the final manusript.

Ethical Approval

 This study titled “Embracing Doctors as Teachers: Evaluating the Student-led Near-Peer Teaching at Transnational Campus” was approved by the Research Management Committee and the Newcastle University Ethics Committee (Approval number 45070/2023).

Data Availability

The data that support the findings of this study are openly available in Figshare repository, as below,

https://doi.org/10.6084/m9.figshare.26886517.v1 (Tang et al., 2024a) and

https://doi.org/10.6084/m9.figshare.26886514.v1 (Tang et al., 2024b).

Acknowledgement

The authors would like to thank the NUMed Medical Education Society for carrying out this programme. The authors are grateful for Professor Vishna Devi Nadarajah for her support and feedback in this research.

Funding

The authors declare that there is no funding received in this study.

Declaration of Interest

The authors declare that there is no conflict of interest.

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*Kye Mon Min Swe
1, Jalan Sarjana 1, Educity,
79200 Iskandar Puteri, Johor, Malaysia
Email: kye-mon.min-swe@newcastle.edu.my

Submitted: 13 June 2024
Accepted: 4 February 2025
Published online: 1 July, TAPS 2025, 10(3), 26-36
https://doi.org/10.29060/TAPS.2025-10-3/OA3439

Humairah Zainal¹, Xin Xiaohui¹, Julian Thumboo^1,2,3 & Fong Kok Yong^2,3

¹Health Services Research Unit, Singapore General Hospital, Singapore; ²Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, ³Duke-NUS Medical School, National University of Singapore, Singapore

Abstract

Introduction: As healthcare becomes increasingly digital, undergraduate medical students receive limited formal training in digital healthcare technologies (DHTs). Additionally, stakeholders’ perspectives on essential digital health competencies (DHCs) across generations remain underexplored. This comparative study aims to identify knowledge gaps, inform evolving expectations, and promote continuous learning by comparing medical students’ and senior clinicians’ views on essential DHCs in Singapore.

Methods: Individual semi-structured interviews were conducted with medical students, clinical educators, and clinical teachers. Clinical-year medical students from all three local medical schools were recruited using convenience and snowball sampling, while purposive sampling ensured diverse representation of clinicians across Singapore’s public healthcare organisations, focusing on those engaged in education-related activities. Data were collected from September 2020 to February 2023 until thematic saturation was achieved, and analysed using qualitative thematic analysis.

Results: Sixty-three participants took part, including 30 medical students, 12 clinical educators and 21 clinical teachers. All clinicians had more than 10 years of clinical experience and came from 24 different disciplines and 12 healthcare institutions. The findings showed unanimous support for integrating electronic health records in patient communication, and training in DHTs like telemedicine and point-of-care ultrasound. Discrepancies emerged; clinicians prioritised physical examination, while students viewed it as potentially replaceable by DHTs. Furthermore, while students valued healthcare-related smartphone applications in patient care, few clinicians shared this view, citing privacy and security concerns.

Conclusion: Evaluating stakeholders’ perspectives highlights evolving clinical skills and essential DHCs for medical students, potentially informing global DHC training programmes.

Keywords:           Technology, Medical Education, Curriculum, Clinical Competence, Digital Competence, Qualitative, Singapore

Practice Highlights

• An inter-generational perspective in medical education leverages the strengths of both medical students and senior clinicians, ensuring a balanced approach that keeps pace with technological advancements while maintaining the core principles of patient care.
• The digital health competencies deemed essential for future clinical practice are consistent across all stakeholders.
• The study highlights the emerging need for additional competencies among medical trainees so as to meet the evolving demands of healthcare delivery.
• Regularly comparing the perspectives of various stakeholders in the healthcare system enables educational institutions to adapt and refine their curricula continuously.

I. INTRODUCTION

Digital healthcare, which leverages advanced technologies to enhance, complement, or replace traditional healthcare services, is becoming increasingly common in clinical practice (Alkire (née Nasr) et al., 2020). Digital healthcare technologies (DHTs) such as electronic health records (EHR), telemedicine, and Artificial Intelligence (AI) have significantly improved data management, diagnostics, and patient care (Clay-Williams et al., 2023; Food and Drug Administration, 2019; Welcher et al., 2018;). However, many studies and reviews have highlighted a global lack of formal and systematic training in DHTs for undergraduate medical students (Aungst & Patel, 2020; Edirippulige et al., 2018; Tudor Car et al., 2021). While recommendations for integrating digital health education (DHE) exist, they often propose standalone courses focused on specific DHTs rather than embedding DHE into the core medical curriculum (Tudor Car et al., 2021; Zainal et al., 2023a; Zainal et al., 2023b).  Barriers to consistently incorporating DHE into medical curricula, as reported in countries such as Canada, Germany, the United Kingdom (U.K.), and the United States (U.S.) include limited faculty expertise, curriculum overload and fragmented implementation efforts (Gillissen et al., 2022; Hurley et al., 2011; Machleid et al., 2020; Sit el al., 2020; Sorg et al., 2022).

Furthermore, there is limited research exploring the perspectives of both medical students and senior clinicians on the relevant digital health competencies (DHCs) required for clinical care. DHCs encompass the knowledge, skills, and attitudes essential for assessing, diagnosing, and treating patients in the digital age. An inter-generational comparison of these perspectives is crucial for identifying gaps in the existing curricula and ensuring medical education aligns with the rapidly evolving healthcare landscape. Medical students can offer fresh insights into emerging tools and platforms while senior clinicians can contribute perspectives on clinical skills given their wealth of clinical experience.

Despite Singapore’s advanced digitalisation, challenges remain in standardising DHE across its three medical schools: Yong Loo Lin School of Medicine at National University of Singapore (NUS), Lee Kong Chian School of Medicine at Nanyang Technological University (NTU) and Duke-NUS Medical School (Duke-NUS) (Zainal et al., 2023a). Although these institutions boast state-of-the-art facilities, a disconnect persists between medical training and clinical practice due to various institutional and structural barriers (Zainal et al., 2023a). While efforts to integrate DHE, such as virtual reality courses, have been initiated, there are variations in content and duration across institutions, underscoring the lack of a standardised approach (Zainal et al., 2023a).

This study uses Singapore as a case study to explore the perceptions of medical students, clinical educators, and teachers regarding DHCs, with the aim of improving DHE integration into undergraduate medical curricula. Specifically, it compares the views of these stakeholders in identifying any digital competencies that may be relevant for clinical practice in an increasingly digital healthcare landscape. By focusing on Singapore, this study not only sheds light on gaps in the local curricula but also provides insights that can inform global efforts to strengthen DHE integration in medical education.

II. METHODS

A. Setting and Sample

A qualitative study was conducted using individual semi-structured interviews with medical students, clinical educators, and clinical teachers. Participants were identified by Principal Investigator (P.I.) FKY, based on their year of study and clinical roles respectively, ensuring relevant knowledge and experience.

The study employed a combination of convenience sampling and snowballing technique to recruit students from all three local medical schools. Clinical-year students (third to fifth years) were included due to their potential exposure to DHTs during clinical rotations, while pre-clinical students were excluded. Convenience sampling was initially used for ease of access, and snowballing technique was subsequently employed to expand participation and capture diverse perspectives.

To ensure diverse representation among clinicians, purposive sampling was applied across Singapore’s three public healthcare organisations. Clinical educators dedicating over 20 per cent of their time to education-related activities (e.g., teaching, curriculum planning, research, and administration) and clinical teachers contributing less than 20 per cent of their time to such roles were included. Clinicians not involved in educational roles were excluded from the study.

This study was classified as a quality improvement (QI) project on medical education curricula by the SingHealth Research Integrity, Compliance, and Ethics (RICE) committee. As such, it did not meet the criteria for human subject research and was granted an ethical waiver by SingHealth Institutional Review Board (Reference Number: 2020/2880). Nonetheless, this research adhered strictly to the ethical principles of the Declaration of Helsinki and institutional guidelines.

Data collection occurred from September 2020 to February 2023. Participants were invited by the P.I. via email detailing the study’s purpose, procedures, potential risks, and benefits, with consent obtained before the interviews. To address potential biases due to the P.I.’s professional relationships, interviews were conducted by a research fellow without prior connections to participants. Verbal consent was recorded at the start of each Zoom session, and participants were reminded of their right to withdraw, with pre-withdrawal data retained for comprehensive analysis.

To ensure anonymity, participants were assigned coded identifiers (‘MS’ for medical students, ‘CL’ for clinicians). Identifying information and audio recordings were securely stored and separated from the main dataset. Results were reported with care to avoid identifying individuals, and the data was exclusively used for curriculum development.

B. Data Collection

The interview guide followed Kallio et al.’s (2016) framework, including pre-requisites for semi-structured interviews, literature review, expert consultation, preliminary guide development, pilot testing with five participants, and finalisation. Questions addressed clinical competencies, their relevance to digital healthcare, and ways medical schools can better prepare students for digitalisation (Tables 1 and 2). Interviews included medical students and clinicians across specialties to ensure diverse perspectives.

The study involved 63 participants, with sample size guided by theoretical and practical considerations. Data collection continued until thematic saturation was reached, ensuring all relevant perspectives were captured. Practical constraints like time and resources influenced the participant number, but the focus remained on data richness and diversity for a comprehensive exploration of the research questions.

Sixty interviews were conducted via Zoom due to COVID-19 restrictions, with three in-person interviews held under local health guidelines. Each session lasted about 40 minutes and was audio-recorded. Transcriptions were generated using Otter AI and reviewed for accuracy by the P.I. and research fellow.

Table 2. Interview questions for clinical educators and teachers

C. Data Analysis

Thematic analysis followed Braun and Clarke’s six-step framework to explore curricular gaps (Braun & Clarke, 2006). Two researchers independently coded the data, resolving discrepancies through discussion to refine the codebook and ensure consistency. Credibility was enhanced by triangulating findings across participants from various medical schools and healthcare clusters, capturing diverse perspectives and minimising bias.

To contextualise the findings, comparisons were made with studies from other high-income countries undergoing similar healthcare digitalisation. Additionally, recent data from stakeholders, including medical school leaders, were analysed to understand the digital competencies needed for future clinical practice. Reporting adhered to the Standards for Reporting Qualitative Research (O’Brien et al. 2014).

III. RESULTS

Sixty-three participants took part in our study. Thirty of them were medical students who were undergoing clinical rotations in various disciplines, with 10 coming from each school. Twelve were clinical educators and 21 were clinical teachers. The clinicians were aged between 44 and 70 years. All had more than 10 years of clinical experience and came from 24 different disciplines and 12 healthcare institutions. A summary of their demographics is reported in Table 3 and illustrative excerpts are found in Table 4.

Table 3. Demographics of participants

Four major themes were derived from the data.

A. Limited and Inconsistent Exposure to DHTs

Students reported limited exposure to DHTs in core medical curricula, with training mainly through electives, select programmes, and student-driven initiatives. Exposure to health informatics and telemedicine was brief, with telemedicine training primarily prompted by the COVID-19 pandemic. Other DHTs like robotic surgery, virtual reality, and POCUS were inconsistently incorporated across medical schools. Some clinicians also reiterated the need for DHT exposure in public healthcare institutions, as doing so could inspire medical students to engage in innovation, research, and development in cutting-edge fields like robotics.

B. Unified Views among Clinicians and Students on Essential Competencies

Clinicians and students shared unified perspectives on incorporating key DHCs like EHR, telemedicine, and POCUS into medical curricula. These competencies are viewed as crucial for preparing students for contemporary clinical practice.

Participants emphasised the need to balance EHR use with effective patient interaction. M25, a third-year student, highlighted the importance of maintaining empathy and humanistic values, while CL27, a rheumatologist, stressed integrating EHR data into patient discussions to improve engagement and understanding of health conditions.

All groups also agreed on the importance of telemedicine training. Students expressed interest in learning how to identify conditions suitable for virtual consultations, build patient rapport, and conduct comprehensive assessments via tele-platforms. MS5 noted the challenges of teleconsultation, such as interpreting body language and addressing legal responsibilities. Clinicians like CL14 underscored the need to teach students how to select patients for teleconsultation and identify red flags effectively.

Additionally, both clinicians and students strongly supported incorporating POCUS into the curriculum. Students acknowledged its utility in bedside diagnostics, while clinicians like CL9 and CL18 highlighted its value in resource-limited settings and its role in enhancing diagnostic accuracy. They advocated for routine training in ultrasound, considering its increasing use in general practice and as a critical tool in diverse healthcare settings. These unified views suggest the need to prioritise these DHCs in medical education to meet the evolving demands of healthcare delivery.

C. Divergent Opinions on Traditional Clinical Skills

Discrepancies in opinions emerged regarding traditional clinical skills, particularly physical examination. Students often viewed diagnostic imaging and tests as superior to these skills, perceiving physical exams as less critical. For instance, M11, a Year 4 student, argued that ultrasonography provides more precise diagnoses, making physical examination less relevant.

Clinicians, however, emphasised preserving traditional skills like history-taking and physical examination, especially for resource-limited settings. CL3, an ophthalmologist, expressed concern that reliance on diagnostic tools has led to the erosion of these essential skills.

D. Emerging Technologies and Concerns

The perceived competencies for medical education varied between students and senior clinicians. Students valued wearables and healthcare apps for patient empowerment, personalised care, and strengthening doctor-patient trust. For instance, MS30, a fourth-year student, suggested that wearable data could help create personalised care plans and enhance clinical practice.

Clinicians, however, expressed concerns about the privacy and security of patient data in these apps. They emphasised the responsibility to protect patient information and were cautious about using apps that did not meet security standards. These differing opinions highlight the need for a DHE curriculum that addresses both student interests and clinician concerns.

In our sample selection, we included both clinical educators and clinical teachers to capture a range of perspectives on the integration of DHCs into medical education. However, our analysis did not reveal significant differences in the views expressed by these two groups. Both shared similar opinions on the importance of teaching DHCs such as EHR, telemedicine and POCUS. This alignment may be attributed to their shared roles in preparing medical students for clinical practice, regardless of their specific titles or responsibilities. As such, the findings reflect a unified perspective among clinicians involved in medical education, despite the initial distinction made in the sample selection.

Table 4. Illustrative quotes from interviews with participants

IV. DISCUSSION

This study contributes to the literature by comparing the views of medical students, clinical educators, and clinical teachers on essential competencies for medical school curricula. It highlights a consensus on the need for training in EHR, telemedicine, and POCUS, while also identifying emerging needs like interpreting data from healthcare devices and engaging patients with this data. Unlike previous studies that focused on either clinicians or students (Blacketer et al., 2021; Foadi et al., 2021; Gillissen et al., 2022; Hersh et al., 2017; Liu et al., 2022; Machleid et al., 2020; Pontefract & Wilson, 2019), this research explores inter-generational differences, revealing that younger trainees prioritise patient-centred care and digital health literacy. This emphasis on inclusivity and data literacy is crucial given the global challenge of inadequate health literacy, particularly among older populations (Sørensen et al., 2021; Wittink & Oosterhaven, 2018). Integrating these competencies into curricula can foster ongoing improvement in medical education.

In comparing the views of medical students and senior clinicians regarding DHCs, it is important to acknowledge that the latter group represents a diverse range of roles within the clinical environment. While this study focused specifically on clinicians involved in medical education, senior clinicians may also take on roles as clinical researchers, administrators, or leaders in healthcare innovation. These differing responsibilities could shape their perspectives on the DHCs that should be emphasised in medical curricula. The results of this study should be interpreted within the context of the clinical educators’ primary role in teaching medical students, which may prioritise practical and immediate clinical skills over broader administrative or research-based digital competencies.

The integration of EHR systems into medical education has been recognised as essential. Successful models in the U.S. and U.K. have embedded EHR systems into training, such as allowing students to write notes at primary clinical sites or use de-identified patient data for practice (Pereira et al., 2018; Pontefract & Wilson, 2019; Welcher et al., 2018). These approaches ensure hands-on learning and prepare students for modern healthcare environments. For broader applicability, partnerships with local healthcare institutions and technology providers can enable the development of localised EHR modules tailored to different healthcare contexts. However, over-reliance on EHR systems may reduce critical thinking or direct patient interaction. Mitigation strategies include embedding reflective practices into training and balancing EHR use with patient engagement activities. When successfully implemented, EHR training enhances data management skills and promotes patient interaction.

Telemedicine training varies globally, often focusing on rural healthcare placements, as seen in Australia and the U.K. (Rienits et al., 2016; Wootton, 1999). In Singapore, telemedicine exposure arose mainly during the COVID-19 pandemic’s social distancing requirements, highlighting its potential in urban healthcare. To ensure comprehensive telemedicine training, curricula should include simulated consultations, role-playing exercises, and coverage of diverse scenarios, such as breaking bad news over digital platforms. To address the challenge of interpreting body language, medical schools should incorporate modules that focus on interpreting non-verbal cues, such as facial expressions and gestures, which are essential for building rapport and understanding patients’ concerns. Courses that address the legal responsibilities in telemedicine, including patient confidentiality, informed consent, and documentation requirements, should also be integrated to ensure students are aware of the regulatory frameworks guiding virtual care. Case studies and real-life examples that discuss the legal implications of telemedicine can also help students navigate potential legal challenges. With regard to patient selection, it is crucial for professional bodies to develop frameworks that guide clinicians in determining when in-person care is more appropriate, especially for complex or high-risk cases. Additionally, the curricula should provide guidance on how to recognise red flags such as signs of mental health distress, urgent medical conditions, or patient non-compliance with digital tools, and escalate them appropriately. Providing continuing education opportunities for practising clinicians is also important to keep them updated on telemedicine advancements. The healthcare system can then pair students with experienced telemedicine practitioners who can provide the necessary mentorship and guidance.

POCUS has become an essential component of undergraduate medical education (Glass et al., 2021; Sheppard et al., 2023). However, its application is often limited to specific specialties, such as emergency medicine, obstetrics and gynaecology, and radiology (Glass et al., 2021). In contrast, our study advocates for a longitudinal POCUS curriculum spanning all years and specialties. Integrating POCUS training into medical curricula improves diagnostic accuracy, enhances bedside decision-making, and builds clinical confidence. A structured approach, such as Kern’s six-step model, provides a robust framework for designing and implementing a standardised curriculum with consistent competency assessments (Kern, 1998). Innovative teaching methods, including handheld devices and near-peer instruction, have been shown to improve ultrasound proficiency and student performance, as evidenced by successful implementations at the University of Connecticut School of Medicine (Boivin et al., 2022). While improper use of POCUS can result in diagnostic errors, these risks can be mitigated through routine competency evaluations and guided practice, ensuring students develop the necessary skills safely and effectively.

Addressing differing opinions regarding DHC priorities in schools requires collaboration among medical educators, technology developers, and healthcare providers. Medical curricula should include training on the responsible use of DHTs, and evaluating the reliability of apps. Developers should design apps that address clinicians’ data security concerns. Moreover, healthcare organisations should establish guidelines and protocols for healthcare-related app use to ensure patient safety and privacy. Integrating these competencies into medical curricula will better prepare future healthcare professionals for evolving demands of healthcare delivery.

Implementing DHC also requires consideration of diverse healthcare systems and resource availability. Local adaptations, coupled with ongoing evaluation and feedback, ensure curricula remain relevant and scalable. Training programmes must balance global standards with local needs, enabling students to navigate evolving healthcare landscapes effectively. By addressing the implementation strategies, risks, and benefits of DHTs, this study provides actionable insights for advancing DHE.

A. Strengths and Limitations

This qualitative study highlights the DHCs needed in the core medical curricula from the perspectives of students, clinical educators and teachers. The diverse sample of institutions and specialties enriched the data. Student feedback provided up-to-date information on curricula gaps, while senior clinicians’ experience enhanced credibility. Interviewing participants from different generations ensured medical education remains relevant to current and future healthcare needs.

A perceived limitation of this study is its small sample size, which may affect its generalisability, validity and reliability. With a small sample, the findings might not represent the broader population and could miss the population’s diversity (Sandelowski, 1995). Additionally, small sample sizes may not adequately capture the diversity within the population of interest (Sandelowski, 1995). Moreover, the unique socio-political, cultural and economic context of Singapore may limit the generalisability of our findings to other settings. Singapore’s relatively small population and centralised governance create conditions that may differ from other countries. Consequently, while the insights from our study provide valuable lessons, they should be interpreted with caution when applying them to contexts with different governance structures or cultural dynamics.

Despite the limitations, this qualitative study provides a contextualised understanding of participants’ expectations and concerns through in-depth narrative analysis. While not entirely generalisable, the findings have significant implications for medical curricula in other developed countries. They highlight valued competencies, informing curriculum design, training programmes and continuing education initiatives.

Furthermore, this study focused on clinicians from public healthcare institutions, which may influence their perspectives on DHCs. Public sector clinicians often work within more structured systems that prioritise certain competencies differently than in the private sector. While this focus provides insights specific to public healthcare education, it is important to note that the views of private-sector clinicians, who may face different digital health challenges, were not captured in this study. Future work comparing clinicians across both sectors could provide a more comprehensive view. The perspectives of clinicians from the private healthcare sector may also differ due to the distinct operational and financial frameworks in which they practise. 

Moreover, future research could explore the perspectives of clinicians in various roles beyond medical education, such as clinical researchers, healthcare administrators, or those involved in clinical governance. By comparing these viewpoints with those of clinical educators, a more comprehensive understanding of the DHCs required across different professional pathways in healthcare can be developed. Such studies could further inform curriculum development to ensure that medical students are adequately prepared not only for clinical practice but also for the evolving demands of digital health in research, administration, and leadership.

V. CONCLUSION

In conclusion, an inter-generational perspective in medical education leverages the strengths of both medical students and senior clinicians, ensuring a balanced approach that keeps pace with technological advancements while maintaining the core principles of patient care. This collaborative model prepares future healthcare professionals to navigate the evolving landscape of healthcare technology effectively. As the findings have shown, despite their varying levels of experience and diverse medical backgrounds, the DHCs deemed essential for future clinical practice are consistent across all stakeholders. While all stakeholder groups considered most basic clinical skills important, medical students viewed physical examination as replaceable by DHTs. In contrast, the clinical educators and teachers thought otherwise. To address the needs and concerns of all groups, DHCs should complement instead of replace traditional clinical skills.

We acknowledge that the DHTs deemed important in other countries may vary from those reported in this study. However, the type of DHTs to be introduced should not distract us from the main goal of ensuring that the curricula of medical schools around the world remain updated and relevant to current and future healthcare needs. Regularly comparing the perspectives of various stakeholders in the healthcare system is crucial, as it enables educational institutions to adapt and refine their curricula continuously. This iterative process ensures that the curricula remain responsive to the dynamic nature of clinical work.

Notes on Contributors

Humairah Zainal collected and analysed the data, wrote the initial drafts, revised the manuscript for publication and approved the submitted copy of the manuscript.

Xin Xiaohui reviewed, edited, read and approved the submitted copy of the manuscript.

Julian Thumboo reviewed, edited, read and approved the submitted copy of the manuscript.

Fong Kok Yong was involved in the conception and design of the study, reviewed, edited, read and approved the submitted copy of the manuscript.

Ethical Approval

Waiver for ethical approval was granted by SingHealth Institutional Review Board (Reference Number: 2020/2880). 

Data Availability

The data that support the findings of this study are available from the first author upon reasonable request. The data cannot be uploaded to the repository as it contains some confidential views of participants.

Acknowledgements

The authors extend their gratitude to the reviewers for their insightful feedback on the manuscript drafts. Special thanks go to Anisa Muhammad for transcribing the interviews, as well as to Dr. Warren Fong Weng Seng and Dr. Ng Qin Xiang for their assistance in recruiting some of the medical students. The authors also deeply appreciate the invaluable contributions of the study participants.

Funding Statement

This study was supported by SingHealth Duke-NUS Medicine Academic Clinical Programme under Seah Cheng Siang Distinguished Professorship in Medicine.

Declaration of Interest

There are no relevant financial or non-financial competing interests to report.

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*Fong Kok Yong
10 Hospital Boulevard
Singapore 168582
+65 6908 8949
Email: fong.kok.yong@singhealth.com.sg

Submitted: 29 February 2024
Accepted: 5 February 2025
Published online: 1 July, TAPS 2025, 10(3), 15-25
https://doi.org/10.29060/TAPS.2025-10-3/OA3259

Zaw Phyo¹, Titi Savitri Prihatiningsih², Ye Phyo Aung¹ & Tun Tun Naing¹

¹Department of Medical Education, Defence Services Medical Academy, Yangon, Myanmar; ²Public Health and Nursing Universitas Gadjah Mada, Yogyakarta, Indonesia

Abstract

Introduction: The effective implementation of changes in medical school curricula requires modifications to assessments alongside teaching strategies. The World Federation for Medical Education emphasises the need for assessment policies to align with educational outcomes. In Myanmar, the Defence Services Medical Academy (DSMA) has adopted an outcome-based curriculum since 2017, but the standard setting in assessments remains pending. This study explores concerns and challenges for enhancing assessment practices.

Methods: An explanatory sequential design was used. For a quantitative approach, 36 assessment committee members were surveyed using questionnaires, and pre-and post-test analyses were conducted using SPSS Statistics Version 25. Qualitatively, eight committee members were selected through purposive sampling for in-depth interviews using interpretative methodology with thematic analysis by MAXQDA Software 2022.

Results: It shows that most committee members acknowledge the advantages of standard settings, such as improved teaching and learning defect identification, staff knowledge application, enhanced educational programs, and personal contributions to education quality. Half of the committee members expressed concerns about the increased workload and administrative burden, while another half-supported standard-setting implementation. They all appreciate the integration of standard setting in the outcome-based curriculum, recognising its positive impact on student quality and accreditation standards. Challenges include limited human resources, resistance to change, time-consuming, and an increased workload.

Conclusion: Committee members suggested that targeted interventions are needed to improve awareness, collaboration, and successful implementation. These should consider perspectives, enhance understanding, define roles, and address resources and resistance. This will optimise standard setting, ensure educational quality, and meet accreditation standards.

Keywords:           Assessment, Standard Setting, Integrated Curriculum, Awareness, Perception, Attitude, Lifelong Learning

Practice Highlights

• Members of the committee think that having standards in DSMA’s curriculum is essential for raising the quality of students and the school’s standards.
• Most members know how important it is to set standards, especially for pass/fail exams, and stress how important it is to consider culture and institutional factors.
• Setting standards is thought to help with aligning the curriculum, giving students relevant tests, and meeting accreditation requirements.
• For implementation to go well, all stakeholders must be involved, the process must be in line with real evaluation principles, and teachers must continue to learn and grow.
• Not enough resources, resistance to change, limited time, and more work to do are problems that need solutions based on educational ideas.

I. INTRODUCTION

In the last 30 years, there have been many suggestions for changing the curriculum, but only a few medical schools have made significant changes (Supe & Burdick, 2006). Without altering assessments, modifying curricula or teaching strategies will be ineffective. In the global standards for quality improvement area of the World Federation for Medical Education (WFME), there are clear rules about primary medical education in chapter 3.1 of Assessment Policy and System:

“An assessment policy with a centralised system that guides and supports its implementation will entail using multiple summative and formative methods to acquire the knowledge, clinical skills, and behaviors needed to be a doctor. The policy and the system should be responsive to the school’s mission, specified educational outcomes, available resources, and the context” (World Federation for Medical Education, 2020).

In current Medical Education, with competency-based education becoming more popular, healthcare educational institutions and assessment bodies are being looked at more closely than ever before to make sure they are fair, transparent, and defensible when setting the expected level of performance and rating students’ performance to make decisions about their next steps (Lane et al., 2020). With competency-based assessment, the way the test is done must align with what the student has learned (Crespo et al., 2010).

Regularly setting, keeping, and evaluating assessment standards is essential in medical education. It is not an exact science to set standards. Most educational test validity arguments focus on how well the test matches the curriculum and how valuable the test’s content is (Barman, 2008).

Standards are an expression of values, so the ways to set them are systematic ways to gather people’s opinions on values, make agreements, and show that agreement as a single score on a test (Norcini, 2003). “Standard Setting” is a process used to make precise lines between things like “pass” and “fail” or “honors,” “proficient,” and “needs improvement.” Setting standards is “central to giving meaning to test results and, as such, is at the heart of validity arguments” (Wiliam, 1996).

There are two primary methods in which standards are set: (1) criterion-referenced or absolute methods, in which standards setting is not based on test results, and (2) norm-referenced or relative methods, in which setting standards is based on test results. No golden rule exists (Cohen-Schotanus & Van Der Vleuten, 2010).  In health professions education, it can be challenging to develop credible, defendable, and acceptable passing or cut-off scores for exams (Norcini & Guille, 2002).

In Myanmar, there are currently no private medical schools, although there are five public medical schools and one military medical school (Defence Services Medical Academy). Myanmar medical schools have used traditional lecture-based teaching methods, and many eminent physicians have emerged from teacher-centered educational programs (Myint, 2020).

Defence Services Medical Academy (DSMA), listed in the World Directory of Medical Schools, was founded in Mingalardon, Yangon, on November 19, 1992 (Naing et al., 2022). Since 2017, DSMA has been the first medical school in Myanmar to implement an outcome-based, integrated curriculum. According to the Dundee three circle models, the graduates of DSMA are supposed to be scholars and scientists, as well as practitioners and practitioners professionals (Harden et al., 1999).  The new DSMA curriculum is meant to encourage students to keep learning and give them more responsibility for their learning. It is presently focusing on meeting the criteria of WFME accreditation.

In DSMA, the assessment methods (written, practical, oral, and structured and unstructured observations) include accurate and standardised patients, objective structured clinical examination, patient management problems or simulations, etc. The assessments include continuous assessment, formative assessment, and summative assessment. However, there is no Standard Setting in DSMA, and it will be implemented soon (after training standard setting experts) to set the required basic minimum standards.

Even though accrediting organisations advise medical schools in general what the curriculum should cover and how it should be tested, most medical schools decide how and what to test (Epstein, 2007). There are five ways to figure out how valuable a method of assessment is: reliability (how accurate and repeatable the measurement is), validity (whether the assessment measures what it says it measures), impact on future learning and practice, acceptability to students and teachers, and costs (Van Der Vleuten, 1996). Therefore, the Assessment Committee’s DSMA meetings establish the process and procedures for conducting assessments throughout the undergraduate medical program. The Assessment committee must collect and evaluate feedback regularly, and faculty feedback revealed issues with the assessment process in DSMA.

 For a successful, acceptable, and feasible assessment to implement an outcome-based, integrated curriculum, it is essential to explore how students, faculty, and assessment committee members perceive the implication of the standard setting for the assessment. Therefore, this study investigated what the Assessment Committee members think about setting standards in medical education and the most significant problems.

II. METHODS

A. Research Design

Figure 1 shows explanatory sequential mixed methods design (also called a two-phase model (Creswell & Clark, 2017)): Quantitative followed by qualitative was used to explore the views, opinions, beliefs, and feelings of the assessment committee members (Ivankova & Stick, 2007). For the quantitative, all assessment committee members were asked using questionnaires (Likert scale), and qualitatively, Individual In-depth Interviews (IDI) were asked of the selected assessment committee members.

Figure 1. Explanatory sequential mixed methods design

The main benefit of mixed methods research is that they make a potent mix when quantitative and qualitative data are combined (Miles & Huberman, 1994). In addition, a “complex” image of a social phenomenon might be created, for instance, by evaluating both the quantitative and qualitative aspects of a study’s results (Greene, 2006).

B. Data Collection

For Phase 1 (Quantitative): The survey consists of four parts: (1) Collecting demographic information; (2) Investigating people’s perception of standard-setting procedures; (3) Examining attitudes towards these procedures; and (4) Evaluating these procedures using five-point Likert scale items ranging from 5 (strongly agree) to 1 (strongly disagree).

For Phase 2 (Qualitative): An in-depth interview (IDI) with semi-structured questions was used to collect the data. The researcher made an interview guide, which helped shape the interview and get detailed comments from the assessment committee members. The IDIs lasted 30-45 minutes, and the researcher informed participants that their names and information would be kept private.

The researcher performed all the interviews in the participants’ local language (Myanmar). The IDI explored the themes of the conceptual framework. A video recording was made for continuous recording in a quiet, private section of the medical education department office. The researcher conducted open discussions with the assessment committee members and kept them confidential, especially the students. Each interviewer uses a different set of questions (10–12), and the sessions last between 45 and 60 minutes. The researcher kept doing interviews until it became clear that the stories, themes, and problems had been covered to saturation point. The researchers utilised constructivist reflexivity throughout the entire study procedure, as advised by Alvesson and Sköldberg (2017).

C. Sampling Procedure

In DSMA, there are 38 members of the assessment committee. The assessment committee comprises three groups: Discussant members, voting members, and secretariat.

For Phase 1 (Quantitative): All the assessment committee members of DSMA were recruited. Among the 38 eligible persons who met eligibility, approximately 95% of the population (36 participants) responded to the evaluation survey.

For Phase 2 (Qualitative): By using the purposes sampling methods, individual in-depth interviews (IDIs) with semi-structured questions were given to the selected eight members of the assessment committee who are information-rich persons (two discussant Members, five voting members, and one secretariat) to find out what they thought, what they had done, and how they did it.

D. Data Analysis

The survey data was stored in an Excel file and processed using SPSS software (version 25). Descriptive analysis explored assessment committee members’ perceptions, attitudes, and practices.

The MAXQDA 2022 program extracted themes and sub-themes (Côté & Turgeon, 2005). The recorded interviews were transcribed to do content analysis. First, the data were summarised, proofread, and translated into English. Second, for the data analysis, themes, sub-themes, and clusters were identified (Cresswell, 2012). Finally, conceptualisation and explanation throughout the later stages led to the development of concrete abstracts. Analytic coding was done while reading the transcripts, and emerging issues were thought to be included in the thematic statements.

E. Ethical Considerations

The study was done according to the guidelines published by the Ethical and Research Committee of DSMA. Participation in this study is entirely voluntary.

F. Informed Consent

Before conducting the study, informed verbal consent was obtained for respondents’ autonomy to participate in this study.

III. RESULTS

Quantitatively, thirty-seven questions were asked about each participant’s background, knowledge, perception, attitude, and practices regarding the standard-setting. The survey received responses from 36 participants. The data supporting this study’s findings are openly available in the Figshare repository, https://doi.org/10.6084/m9.figshare.25657875.v1 (Phyo et al., 2024).

A. Demographic Characteristics

According to an analysis of the committee’s demography (see Table 1), two-thirds of the members were older than 25, and males dominated. Faculty members (64%) were primarily doctoral holders on the evaluation committee. More than ten years of teaching experience can be found among half of the assessment committee members.

Table 1. Personal background information of the assessment committee members

B. Awareness of Standard Setting

In Table 2, most assessment committee members believe that DSMA has been implementing a standard setting in the assessment process, but it is still in the process of being fully implemented. However, 75% know the purpose behind establishing standard settings in DSMA. Furthermore, faculty members are debating whether DSMA is a precise standard-setting approach for standardisation and how DSMA intends to implement whatever assessment model.

No	Question	Answers	Total (n=36)
			Frequency	Percentage
1	Does DSMA have a standard Setting in the MBBS Programme?	Yes	23	63.9
		No	11	30.6
		Uncertain	2	5.6
2	Who Is the most Responsible person in the Implementation standard setting within DSMA?	Rector	9	25.0
		Assessment Committee	6	16.7
		All Staff	20	55.6
		Uncertain	1	2.8
3	Why did DSMA introduce a Standard setting?	Rector’s foresight and planning	8	22.2
		Requirement of MMCAC guideline	27	75.0
		Uncertain	1	2.8
4	How many types of standard settings?	One	6	16.7
		Two	22	61.1
		Three	8	22.2
5	The assessment system of the DSMA is designed by applying a ready-made model like programmatic assessment.	Yes	12	33.3
		No	12	33.3
		Uncertain	12	33.3
6	Does DSMA have an exact standard-setting method to standardise the assessment system?	Yes	17	47.2
		No	10	27.8
		Uncertain	9	25.0

Table 2. Awareness of standard setting

Table 3. Perception, attitude, and practice towards standard setting

The attitudes section indicates lower ratings (2.0–3.0) with worries about increasing workload (59% agreement) and administrative burden (56% agreement), revealing resistance or uncertainty among some staff members towards the practical implications of standard setting. They also feel that implementing standards creates an uncomfortable academic environment, but 81% think the standard-setting process is successful (4.0 ± 0.7).

The high mean scores (4.0–4.4) and agreement percentages (up to 88%) in sections on perceptions and practices indicate strong support for standard setting among respondents. This suggests a recognition of its value in improving educational quality.

The data suggests that standard settings are supported, but there’s a need for more engagement and clear communication about its processes. Apprehension about workload and administrative tasks may stem from a lack of understanding or poor implementation strategies. Institutions could benefit from transparent, inclusive, and efficient management of standard-setting processes, including regular updates, training sessions, and support systems. A balanced approach is needed to address apprehensions and ensure positive outcomes for educational quality and student success.

D. Thematic Analysis Outcomes

The participants were Assessment Committee Members (n=8) from the Assessment Committee of the DSMA who were involved in developing the Standard setting for the Assessment.  The data collected from IDIs were organised into five themes and 19 sub-themes in Figure 2.

Figure 2. Showing the main themes and sub-themes

1) Perceptions of the assessment committee members: The assessment committee members expressed appreciation for the incorporation of standard setting in the Outcome-based Integrated curriculum at our university. Most committee members showed enthusiasm for using this method, which they believed was fitting for assessing students in this program. Additionally, the committee aimed to enhance the assessment techniques used in the Outcome-based Integrated curriculum. They were convinced that implementing standard settings would improve student and DSMA quality.

“An outcome-based integrated curriculum has replaced DSMA’s old curriculum. The product of an outcome-based curriculum is not produced. So, we must prepare for that product to be assessed using the standard setting. It is a transitional period for our DSMA from the old curriculum to the outcome-based curriculum. So, the state holders and teachers from DSMA must understand the standard setting. We must set the standard for the assessment of DSMA, but slowly and steadily.”

(Participant 1)

“If the integrated curriculum is changed and outcomes are improved, the quality of the university will improve. Local or international qualifications will be enhanced, not only by students but also by the quality of the DSMA.” 

(Participant 3)

2) Understanding of standard settings: It was evident that members emphasised the importance of standard setting, particularly in the context of Pass/Fail exams for students. Furthermore, committee members demonstrated knowledge regarding various types of standard setting. They were able to identify the most suitable method for DSMA, taking into consideration factors such as cultural context and institutional requirements.

“The standard setting is a method designed to determine a student’s pass or fail scores, and it is also a technique for determining whether students will pass or fail a test.”

(Participant 4)

“DSMA has to set standards for the assessment according to our culture, values, and conditions. We have taken the standard setting of another prestigious university as a reference. It is not suitable to apply the ready-made model.”

(Participant 1)

3) Benefits of implementing standard settings: The assessment committee members recognised Standard Settings are essential for effective curriculum alignment, meaningful student assessment, and accreditation. DSMA can demonstrate its commitment to delivering high-quality education and meeting accreditation standards by aligning the curriculum, teaching practices, and assessments through Standard Settings. The committee members believe Standard Settings play a crucial role in enhancing the quality of education DSMA provides.

“It is beneficial for constructive alignment. So, we adopted and prepared the standard setting for assessing DSMA for accreditation. It is also essential for the teaching and learning process and method. We can check the teaching and learning process, and if errors occur, we can fix them and circle again for the following year.”

(Participant 1)

“I think the outcomes that come out improve not only the student’s quality but also the DSMA’s quality. If the integrated curriculum is changed and outcomes are improved, the quality of the university will improve. Local or international qualifications will be enhanced, not only by students but also by the quality of the DSMA.”

(Participant 3)

4) Roles and responsibilities while implementing standard setting in DSMA: The Assessment Committee members recognised the critical roles and responsibilities of implementing standard setting. They emphasised the need for an inclusive approach involving all stakeholders. Furthermore, they highlighted the importance of aligning standard setting with authentic assessment principles and providing continuous professional development for faculty members. By considering these factors, the committee members aimed to enhance the quality of assessment and promote meaningful learning outcomes for students.

“The standard setting must be built with support; all teachers at DSMA are responsible for it because only the medical education department knows about the standard setting, which is ineffective. Teachers in all departments, including professors, must know about the standard setting. That’s why all the teachers at the university need to understand when setting standards.”

(Participant 2)

“The assessment committee is in charge of the standard setting in DSMA, including the medical education committee, the curriculum committee, the quality assurance committee, the assessment committee, etc. The assessment committee can emphasise its role and responsibility, including implementing the standard setting. Thus, it is more reasonable and practical.”

(Participant 6)

5) Challenges and weaknesses of implementing the standard-setting: The Assessment committee members identified several challenges in implementing standard setting. These challenges include limited human resources, resistance to change, time-consuming processes, and increased workload. Understanding these challenges through the lens of educational theories can guide the development of strategies to address them effectively and ensure the successful implementation of standard-setting practices.

“Human resources are our main weakness. There are very few human resources in DSMA to apply the standard setting. Time-consuming is another area for improvement.”

(Participant 1)

“Most importantly, students don’t know what a “standard” setting is, and some teachers don’t know either. They need to know what a “standard” setting is.”

(Participant 7)

IV. DISCUSSION

The outcomes from the study at the Defence Service Medical Academy (DSMA) assessment committee shed light on essential aspects of standard-setting in medical education. In institutions like DSMA, which implement the outcome-based integrated curriculum, medical students must remember what they learned in their preclinical training to make sound clinical decisions based on reliable scientific principles (Lazić et al., 2006). In medical education, it is crucial to establish, maintain, and frequently review assessment criteria (Senanayake & Mettananda, 2005).

The study revealed a predominantly male composition within the assessment committee, highlighting the need for diversity and expertise among committee members. While increasing the diversity of academic medical leadership to address the underrepresentation of minorities and women in medicine has been proposed, there has been limited investigation into this topic (Meadows et al., 2023).  Encouraging diversity can contribute to robust discussions and decision-making processes related to standard-setting. While committee members demonstrate a solid grasp of standard-setting, the results indicate a requirement for continual education to translate this knowledge into practical application (Norcini & McKinley, 2007). Therefore, targeted interventions and professional development programs must enhance their knowledge and awareness.

Committee members show favorable attitudes towards standard-setting, but there is a discrepancy between their perceptions and actual practices. Implementing open communication strategies consistent with Downing’s (2005) emphasis on the value of clarity in assessment practices could close this gap. Moreover, the lack of active participation in the implementation process may indicate a more significant engagement problem within academic committees (Van der Vleuten et al., 2010).

The study highlights issues that align with existing literature on medical education reform, citing resource limitations and reluctance to change as typical obstacles to adopting innovative instructional approaches (Swing, 2007). The committee’s alignment with constructivist and cognitive theories advocates for a transition to more interactive and participatory learning methods, which a parallel change in evaluation methods should accompany (Harden & Crosby, 2000). Committee members emphasised the need for an inclusive approach involving all stakeholders and aligning standard-setting with authentic assessment principles, resonating with sociocultural theories emphasising social interaction and collaboration in the learning process.

The findings offer crucial insights into the committee’s perceptions and experiences with standard-setting in the integrated outcome-based curriculum. Aligned with educational theories, these insights underscore the importance of lifelong learning and can guide future research and targeted interventions to continuously enhance standard-setting practices.

V. CONCLUSION

In conclusion, the findings from both the quantitative and qualitative research provide valuable insights into the assessment committee’s knowledge, perceptions, attitudes, and practices regarding standard-setting in medical education at the Defence Service Medical Academy (DSMA). While there is a positive attitude towards the potential benefits of standard-setting, there are also concerns and doubts among some committee members.

The study emphasises the importance of targeted interventions in medical education to improve awareness, address concerns, foster collaboration, and support the successful implementation of standard-setting. The Assessment Committee Members appreciate the incorporation of standard setting in the outcome-based integrated curriculum and recognise its importance during the transitional period. They demonstrate a strong understanding of standard settings, particularly in Pass/Fail exams, and emphasise the need to consider cultural and institutional requirements. Standard settings can enhance curriculum alignment, meaningful student assessment, and accreditation purposes.

The committee members emphasise the roles and responsibilities associated with implementing standard setting, including an inclusive approach, continuous professional development for faculty members, and addressing challenges such as limited human resources, resistance to change, time-consuming processes, and increased workload. Strategies informed by educational theories are needed to improve human resource capacity, provide training on standard setting, and create awareness among students and teachers.

These findings underscore the importance of supporting the assessment committee in their understanding, implementation, and continuous improvement of standard-setting practices. By addressing concerns, providing necessary resources, and promoting collaboration, DSMA can optimise the benefits of standard-setting in medical education and ensure the quality of its educational programs. Incorporating lifelong learning fosters continuous professional development, keeping DSMA at the forefront of educational excellence and adaptability.

Notes on Contributors

Dr. Zaw Phyo contributed significantly to the manuscript development process, including reviewing existing literature, identifying research gaps, and addressing questions and goals. He helped draft and revise the manuscript, emphasising its importance for medical education.

Titi Savitri Prihatiningsih contributed to shaping the research question and framework, ensuring a systematic approach. She applied her expertise in evaluation to refine the research tools and meticulously reviewed the thesis and manuscript for accuracy.

Dr. Ye Phyo Aung engaged in the study’s methodology phase, endorsing the chosen research design, sampling strategies, and data collection techniques, adding valuable insights to the research execution.

Dr. Tun Tun Naing assisted in the meticulous proofreading of the article, ensuring clarity, coherence, and compliance with academic standards.

Ethical Approval

The Ethical Review Committee of the Defence Services Medical Academy,  Yangon, Myanmar, granted ethical approval. (2 / Ethics/ 2021).

Data Availability

The data supporting this study’s findings are openly available in the Figshare repository, https://doi.org/10.6084/m9.figshare.25657875.v1 (Phyo et al., 2024).

Acknowledgment

I would also like to thank the FAIMER Regional Institute of Indonesia for Educational Development and Leadership (FRIENDSHIP) for helping me finish this research project at the Faculty of Medicine, Public Health, and Nursing at Universitas Gadjah Mada (Indonesia).

I would also like to thank my supervisor, the head of the medical education department (DSMA), and my colleagues. Without their help, I would not have been able to survey my research. I am grateful to all the assessment committee members from DSMA, Myanmar, who helped me complete my survey by giving me their valuable opinions and experiences.

Funding

The research was carried out during the study period at the FRIENDSHIP-FAIMER Regional Institute of Indonesia for Educational Development and Leadership. No financing is associated with this publication.

Declaration of Interest

There is no conflict of interest in the current research.

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*Zaw Phyo
No.94, Pyay Road, Mingaladon Township,
Postal code – 1102
Yangon, Myanmar
Phone: 95 92032754
Email: dr.zawphyoo@gmail.com