Submitted: 31 January 2024
Accepted: 22 July 2024
Published online: 1 October, TAPS 2024, 9(4), 68-70
https://doi.org/10.29060/TAPS.2024-9-4/PV3238

Ardi Findyartini^1,2 & Azis Muhammad Putera²

¹Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Indonesia; ²Medical Education Center, Indonesian Medical Education and Research Institute, Faculty of Medicine, Universitas Indonesia, Indonesia

I. ON PROFESSIONAL IDENTITY FORMATION

Professionalism in medicine can be considered as attributes, behaviours, and identity of the professionals who put the needs of their patients and the community they serve above their individual needs. The concept of professionalism is dynamic and might be perceived differently over time, in different contexts, and by different fields, although some ground values like excellence, competence, and altruism might persist. 

Identity formation is an inseparable part of professionalism as it underlines the importance of “being” in addition to the essence of “behaving”. Professional identity formation (PIF) in medical education is both an active psychological process conducted by individuals in internalising their values and others’ expectations. It is also a dynamic socialisation process allowing an individual to be part of the professional community with increasing roles and recognitions. This applies for both medical students who grow to become medical professionals and for medical teachers who probably juggle their different identities as clinicians/researchers to be able to enact their roles as teachers (Cruess et al., 2014).

There is no “one-size-fits-all” rule as to how their PIF should be navigated, as PIF is a journey unique to each individual. The students need to be supported to form their identity from the stage where they just follow the rules to become individuals who can internalise values and expectations from their professional community as an integral part of themselves. The medical teachers, on the other hand, still have to develop their professional identities as teachers and educators in addition to their other identities.

II. CULTURE: WHY DOES IT MATTER?

Given the importance of individual and socialisation processes in PIF, we suggest that it is time for us to consider the influence of cultural factors in students’ and teachers’ PIF. It has been well-established that culture plays a pivotal role in how education is designed, developed, and delivered systematically. However, the frameworks by which medical curricula and faculty development programs are developed, as well as literature informing the commonly understood concepts of PIF, often stem from Western countries. Recent understanding of culture, professionalism, and PIF acknowledges that professionalism is context-specific, with notable differences between norms adopted by the contemporary Western world and in non-Western settings (Al-Rumayyan et al., 2017). Herewith, we use Hofstede’s cultural framework to discuss this matter, where countries are characterised by spectrums of hierarchy, collectivism, uncertainty avoidance, long vs short term orientation, femininity vs masculinity, and self-indulgence and restraint (Hofstede, 2001).

For instance, our research highlights the importance of culture in the PIF of medical teachers. Four main factors seemed to influence the PIF of medical teachers in our settings: an interplay between internal values and external influences, empowerment of teachers’ roles by early socialisation, experiential workplace learning, and future prospects of their careers as teachers. Looking deeper, we identified several relatively unexplored factors influencing the PIF of our teachers: the importance of divine values and religious beliefs, influence of family, and how their roles are recognised by the society (Wahid et al, 2021).

The influence of religious beliefs and societal recognition on PIF seems to be predominant in Arabic and Islamic countries, something that may not be predominant in Western countries. The strong religious influence built a perception of teaching as an act of good deed and opportunity to enact one’s faith in God, cultivating the motivation to pursue a teaching career. From Hofstede’s framework viewpoint, familial influence plays a critical role in a collectivist society like ours, as proven in our study where the participants’ decision to be medical teachers was strongly influenced by also considering coexisting personal roles in the family (especially evident in female teachers). The existence of a family member acting as a role model and internal decision making in the family also supported the decision to pursue a teaching career (Wahid et al., 2021).

The communality in collectivistic society was also notable, since societal recognition was deemed as a reward to develop oneself professionally, showing a stronger emphasis on social relationship as opposed to the Western counterpart which might put more emphasis on individual values and self-fulfilment. The importance of socialisation was evident as many admitted that early in their teaching careers, they would often shadow their seniors, engage in faculty development programs, and nurture their identity by engaging with students and patients. Interacting with fellow teachers helped them to grow professionally and remind them of their roots, creating a valuable interplay between their internal motivation and external influences. This shows an important implication for faculty development (FD) programs: since FD plays an important societal role in supporting the teachers’ PIF, FD programs should be developed with an emphasis on workplace and social learning (Wahid et al., 2021).

Our study among medical students also emphasises the need to address cultural factors such as high power distance, uncertainty avoidance, and collectivism. Our findings suggest that the role of the learning environment is pertinent. In a hierarchical setting with large power distance like ours, we found that socialisation through the hidden curriculum might result in negative role-modelling, which might hinder students’ professional development. The hierarchical and collectivistic settings also influenced students’ responses to professional dilemmas, causing internal conflicts and confusion as to how they should act later on when misconducts are normalised by their hierarchical environment. Considering the study context, teachers have a great role on students’ PIF through good role modelling and facilitation for students in dealing with ethical and professional dilemmas during their learning process, especially in clinical practice. A practical implication is how our students preferred a more structured approach and clear guidance to develop reflective skills and feedback-seeking behaviour in this setting with high uncertainty avoidance compared with other settings (Findyartini et al., 2022).

Our findings suggest that PIF is indeed a fluid process and socialisation is essential. Many students admitted as they got involved further in their medical education journey and continuously reflected on their experience, they were able to understand the complexity of their PIF more. Many were aware about their psychological journey into becoming a professional and how they continuously internalise the traits expected of a professional. External influences like the hidden curriculum, the learning environment, and the behaviours of their peers seemed to intercalate with their initial motivations through continuous socialisation forms, showing a dynamic psychosocial transition (Findyartini et al., 2022).

III. RETHINKING CULTURE AND PIF: THE IMPLICATIONS

We propose two major ways by which culture influences PIF. First, it dynamically influences the societal expectation of professional traits. This should pose some questions, like what kind of professionals does the community need? How does the community currently, and probably in the near future, perceive what a professional is? By this first understanding of ours, it is then pertinent to continuously reflect and identify the needs of the community in defining the traits of a professional. Thus, simply adopting findings from Western literature might not be beneficial and results must be interpreted contextually, and this should call for further studies on professional identity formation in diverse socio-cultural contexts. We would also like to reiterate that professionalism is a temporal and contextual concept, and this will be continuously reinterpreted and redefined with influence from scientific breakthroughs, industrialisation, and globalisation. 

Second, we think of culture as a subtle yet powerful force saliently affecting the process to reach the intended outcome i.e professional identity, as elaborated before. Culture exerts substantial influence on the development process itself, and this is where culture operating on individual and institutional levels, we argue, plays a critical role. Take, for example, our findings on how our students preferred a more direct, structure-driven, and clear guidance in navigating their professional development, or how our teachers were greatly driven by religious beliefs and familial motivation. The communality informs how curriculum for students and FD programs for teachers could be developed. The concepts of intertwining roles of each unique individual student/teacher and the socialisation process involving the learning environment, role models and relevant experiences play a pivotal role in this matter. Curricula and FD program should be developed around the concept of the target as subjects with their own internal values and preferred ways of thinking and doing influenced by the communities of practice around them. We would like to also underscore that the PIF of students and teachers are very much interrelated and we expect that students’ PIF will be highly facilitated by the teachers whose PIF as educator is well internalised.

To summarise, we would like to reemphasise the role of culture and understanding of cultural diversity in the context of PIF. We urge students, teachers, and educators to look at and understand culture as a subtle force driving the aim and process to be professionals. Since socialisation is central in the identity development of both teachers and students, special attention should be given to first reflect and identify cultural values in different levels, most importantly the institution, to develop culturally-sensitive curriculum and faculty development programs.

Notes on Contributors

Ardi Findyartini (AF) currently serves as a Professor of Medical Education and the Head of Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia. AF led the study, developed the ideas, wrote, and critically revised the manuscript.

Azis Muhammad Putera (AMP) is a researcher at the Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia. AMP developed the ideas, wrote, and critically revised the manuscript.

Acknowledgement

The authors would like to thank all teaching and academic staffs of the Department of Medical Education, Faculty of Medicine, Universitas Indonesia, as well as the researchers, research assistants, research interns, and administrative staffs at the Medical Education Center, IMERI, Faculty of Medicine, Universitas Indonesia for the great collaboration by which this paper can be produced.

Funding

The authors received no funding for this work.

Declaration of Interest

The authors declare no competing nor conflict of interests.

References

Al-Rumayyan, A., Van Mook, W. N. K. A., Magzoub, M. E., Al-Eraky, M. M., Ferwana, M., Khan, M. A., & Dolmans, D. (2017). Medical professionalism frameworks across non-Western cultures: A narrative overview. Medical Teacher, 39(sup1), S8–S14. https://doi.org/10.1080/0142159X.2016.1254740

Cruess, R. L., Cruess, S. R., Boudreau, J. D., Snell, L., & Steinert, Y. (2014). Reframing medical education to support professional identity formation. Academic Medicine: Journal of the Association of American Medical Colleges, 89(11), 1446–1451. https://doi.org/10.1097/ACM.0000000000000427

Findyartini, A., Greviana, N., Felaza, E., Faruqi, M., Zahratul, T. A., & Firdausy, M. A. (2022). Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture. BMC Medical Education, 22(1), 443. https://doi.org/10.1186/s12909-022-03393-9

Hofstede, G. (2001). Culture’s consequence: Comparing values, behaviors, institutions, and organisations across nations. Sage Publications. https://doi.org/10.1016/S0005-7967(02)00184-5

Wahid, M. H., Findyartini, A., Soemantri, D., Mustika, R., Felaza, E., Steinert, Y., Samarasekera, D. D., Greviana, N., Hidayah, R. N., Khoiriyah, U., & Soeselo, D. A. (2021). Professional identity formation of medical teachers in a non-Western setting. Medical Teacher, 43(8), 868–873. https://doi.org/10.1080/0142159X.2021.1922657

*Ardi Findyartini
Faculty of Medicine,
University of Indonesia
Salemba 6 Central Jakarta 10430
+62 21 3901814
Email: ardi.findyartini@ui.ac.id

Submitted: 7 October 2023
Accepted: 19 June 2024
Published online: 1 October, TAPS 2024, 9(4), 65-67
https://doi.org/10.29060/TAPS.2024-9-4/PV3154

Justin Wen Hao Leong^*, Yu Bin Tan^* & Bochao Jiang

Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore

*Co-first authors

I. INTRODUCTION

“Teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction”- Hippocratic Oath

Since time memorial, the very act of teaching has been intertwined with that of being a physician. In so far that this tradition is found inscribed in the Hippocratic Corpus dating to the 5^th century BC. Beyond a calling and a duty, the sharing of experience and expertise is also a rewarding aspect of our roles of doctors. In a climate of ever-increasing demands of knowledge and clinical load, it is imperative we hold on to this aspect closely, and simultaneously look to and embrace new mediums to assist medical educators to meet the current challenges. In this article, we share our experience on how we can incorporate X, formerly known as Twitter, as an extra tool to facilitate teaching on the go during ward rounds and promote self-reflection after.

II. THE MEDIUM

X is a leading social medial platform with up to 541 million monthly users (Musk, 2023). Users can create posts, with each post limited to 280 characters with spaces. The term tweetorial, a neologism combining “tweet” and “tutorial”, is a consecutive series of posts that provide coverage of a given topic. One common format of a tweetorial involves the author creating a multi-post thread about a topic, providing a content outline followed by a brief discussion of the topic with links to various societal guidelines or papers. The user interface allows hashtags, images, and weblinks to be embedded into the posts.

Whilst some naysayers have decried the character limit by saying that it eschews complexity, conversely, it is precisely in the form of such brevity that makes it invaluable. For it is this very brevity that forces key information to be distilled in bite-sized teaching points (Breu, 2020).

Increasingly, physicians have been using the platform to disseminate research, share ideas and discuss topics. In the field of gastroenterology, popular hashtags include #Livertwitter or #GITwitter, with several physicians such as @drkeithsiau, @stevenbollipo, @AustinChiangMD from the United Kingdom, Australia and the United States respectively amassing followers of up to 118 thousand with each post on average being viewed thousands of times. The global scale and reach of X is undeniable; despite this, the posts remain personable and accessible, as readers are able to interact with the authors of these directly by liking, reposting, quoting, commenting or bookmarking them.

Whilst these have led to many discourses on the general use of social media in medical education, the ‘how-to’ of incorporating the use of X as a means of teaching on the run to residents and understanding its role in learning theory has not been expounded upon. In this reflection, we share how we can incorporate this medium in the immediacy of facilitating teaching on the run and the learning theories that underpin this.

III. SETTING THE STAGE

Teaching is a pre-planned learning activity, and even teaching on the run in a busy clinical setting can be planned. The crux as educators is firstly, to be keenly aware of the ever-evolving learning needs of our residents, and secondly, to amalgamate the two seemingly antithetical spheres of ‘running to do’ and ‘pausing to teach’ by having on hand an armamentarium of teaching posts that cover the gamut of core and common topics.

One way to be attuned to the learning needs of our residents is to refer to the programme-specific entrustable professional activities (EPAs). First introduced in the Netherlands in 2005, EPAs are discrete and professional core tasks that are speciality-specific. They are independently executable, observable in practice and measurable in output (Ten Cate, 2005). The EPAs clearly defines the need of the residents and across EPAs, span the breath of the content and desired outcomes after graduation from a specific residency programme.

For the educator, recognising the EPAs and imbibing the same shared mental model as our residents, coupled with pre-prepared content provides the chance to deliver a teaching point on a topic on-the-go whenever a given opportunity arises. The aim here is the immediacy of the educational intervention, to guide and stimulate learning in the here and now – to set the stage to seize the teaching moment.

IV. SEIZING THE MOMENT

Whilst covering the inpatient gastroenterology service, our team had a new admission – a young man with a history of chronic pancreatitis had just been admitted for complaints of abdominal pain. He appeared cachexic and was hunched up in bed in pain. After obtaining a history, performing a physical examination and ensuring that the appropriate investigations and medications were ordered, we came together for a short huddle. Just a few weeks prior, we had authored a tweetorial on chronic pancreatitis, covering the definition, pathophysiology, aetiology, diagnostic algorithm, imaging features and complications including pain, malnutrition, exocrine deficiency and cancer.

In the huddle, each member of the team came together, took out their smartphones and independently accessed the given thread on X. We then in a succinct fashion, embarked on a discussion of chronic pancreatitis with the tweetorial providing a scaffold for the discussion.

In cognitive learning theory, the locus of learning is the internal environment of the learner and his or her cognitive structures. The learner uses cognitive tools, including insight, information processing, perception and memory to lock-in the learning by assigning meaning to certain actions. One of the most important aspects of cognitive learning is the development of critical thinking through reflection. This process of reflection can either be a reflection ‘on’ action, where the learner reflects on a situation that has happened, or a reflection ‘in’ action where the learner reflects about the action in the moment, as they are performed. The core, here then, is in seizing the immediacy of such encounters, such that the reflection and synthesising of new knowledge will always be one of reflection ‘in’ action and allow the immediate synapse of what is gleaned to what is previously known.

Before we broke off our huddle to continue with our rounds, our residents could now articulate that more than a patient with a history of chronic pancreatitis presenting with abdominal pain, we had encountered a patient with hereditary pancreatitis with imaging features of pancreatic calcification, ductal lithiasis and intermittent Amman Type B pain who may benefit from a trial of neuromodulators. They then bookmarked the tweet for future reference, and within it, its attendant link to a clinical review paper on chronic pancreatitis for further reading.

V. REFLECTING AND PROPAGATING

Finally, our residents were encouraged to reflect on the topic towards the end of the day (reflection ‘on’ action) by reposting the thread on X and sharing their learning points with regard to the patient encounter and the topic. There were also encouraged to tag fellow residents in the team to further encourage discourse and craft their own new tweetorials on pertinent topics pertinent topics to maximise the use of X as a learning tool (Forgie, 2013).

The spirit of reflection the provides the transition from a cognitivist orientation to a humanist orientation of learning. Within this framework, learning is viewed as a personal act to achieve one’s own full potential with goal that is self-directed and autonomous. This has three main characteristics, firstly, personal involvement by the learner, secondly, learning that is self-initiated, and lastly, learning that is self-evaluated. Taken together, the combination of these three reflects the growth of an independent learner.

The creation of tweetorials by learners thus fosters the development of additional knowledge translation skills by training the learner to first dive deeper into the topic, synthesise knowledge, distil it and lastly, package it with brevity (Tsang, 2023). The learner-created tweetorial then takes on a life of its own online, allowing its own interactions and comments allowing the student to engage in critical thinking and constructive feedback online which in turn transitions into self-evaluation.

VI. CONCLUSION

The traditional Bloom’s taxonomy of remember, understand, apply, analyse, evaluate and create serves as a valuable framework for learning and X, if used appropriately, can be an excellent teaching tool to achieve these educational goals. Initially, the learner ‘consumes’ a tweet in a cognitivist framework, but by bringing the immediacy of the clinical encounter head-on into the screens of their smartphones, the use of X then fast tracks them into applying this new-found knowledge in the current clinical encounter. After the encounter, the learning then shifts into a humanist orientation with the vision of an independent, self-driven and self-critical learner that creates new work; and through this process, take their own steps toward becoming a teacher on the run with an X-tra tool.

Notes on Contributors

Justin Leong and Tan Yu Bin conceptualised the work, drafted the work, revised it and gave final approval of the version to be published. Jiang Bochao drafted the work, revised it and gave final approval of the version to be published.

Funding

There were no funding sources in this paper.

Declaration of Interest

No potential conflicts of interests relevant to this article was reported.

References

Breu, A. C. (2020). From tweetstorm to tweetorials: Threaded tweets as a tool for medical education and knowledge dissemination. Seminars in Nephrology, 40(3), 273-278. https://doi.org/10.1016/j.semnephrol.2020.04.005

Forgie, S. E., Duff, J. P., & Ross, S. (2013). Twelve tips for using Twitter as a learning tool in medical education. Medical Teacher, 35(1), 8-14. https://doi.org/10.3109/0142159X.2012.746448

Musk, E. [@elonmusk]. (2023, July 29). ? monthly users reach new high in 2023. [Image attached] [Post]. X. https://twitter.com/elonmusk/status/1684978651857596429

Ten Cate, O. (2005). Entrustability of professional activities and competency-based training. Medical Education, 39(12),1176-1177. https://doi.org/10.1111/j.1365-2929.2005.02341.x  

Tsang, R., & Pinder, K.E. (2023). The #Tweetorial: An underutilised teaching tool in undergraduate medical education? Medical Science Educator, 33, 583–587. https://doi.org/10.1007/s40670-023-01764-5   

*Justin Wen Hao Leong
31 Third Hospital Ave,
Singapore 168753
Email: justinleongwenhao@gmail.com

Submitted: 9 September 2023
Accepted: 29 January 2024
Published online: 2 July, TAPS 2024, 9(3), 55-57
https://doi.org/10.29060/TAPS.2024-9-3/PV3134

Sean B Maurice

Northern Medical Program, Division of Medical Sciences, University of Northern British Columbia, Prince George, Canada; Cellular and Physiological Sciences, Faculty of Medicine, University of British Columbia, Vancouver, Canada

I. INTRODUCTION

Risk management is a skillset that is embedded within clinical practice. Clinicians use protective equipment to safeguard themselves from pathogens carried by patients, learn de-escalation techniques to manage violent patients, and learn to ask for help. Patients of course are also at risk, because they present with illness or injury that may get worse despite our best efforts, and because there’s always a chance of iatrogenic injury or disease. Healthcare providers dedicate themselves to healing injury and illness, and to not causing further harm. In contrast, risk management is rarely considered with regards to teaching and learning, as they are not commonly understood to involve risk. When a teaching or learning experience feels risky, but we don’t think it should, then we don’t talk about it, and this can create cognitive dissonance and discourage us from engaging in teaching and learning.

Health systems around the world need more healthcare providers, at a time when they are dealing with very significant burnout (Office of the Surgeon General, 2022). In the face of this burnout, we may not be inclined to innovate, but Eva (2022) encourages us to step up and embrace the opportunity to make change, as during challenging times, “… it is critical that every stakeholder in the medical profession strive for excellence by adapting to modern realities rather than clinging to the seemingly safe status quo.” If we need to train more healthcare providers at a challenging time, when not making change is potentially more dangerous than innovating, then we should consider the metaphor of adventure to inspire our innovations and help us think about risk management in teaching and learning.

II. RISKS IN OUTDOOR ADVENTURE

In self-propelled outdoor adventure (hiking, mountaineering, kayaking), risks are largely obvious, and consequences can be very serious, so talking about risk management is both natural and normalised. Participants engage in ‘calculated risk-taking,’ which involves identifying risks and managing them as well as possible to keep the risk at a level considered reasonable by all who partake. Prior to the adventure, risks are managed by ensuring that the team have the right skills, training, and equipment; and judgement is used in choosing the objective and monitoring conditions like the weather, or snow conditions. During the adventure, participants need to make decisions in response to changes that occur over time, including changes in the weather, or the group condition (fatigue, minor ailments like blisters); along with the unpredictable (weather that washes out a key bridge, a bear stole all your food). Additionally, in self-propelled outdoor adventures, the team are limited by the resources that they brought with them, so working as a team to overcome challenges with limited resources is inherent.

For those who choose to embark on self-propelled outdoor adventures as a leisure activity, the idea that fun can involve hard/tedious work and a degree of suffering, is not foreign. Some mountaineers proudly talk about “Type II fun,” with phrases like “It doesn’t have to be fun, to be fun” ­– an acknowledgement that a challenging adventure can be worthwhile even though it involves hard/tedious work, risk, and some discomfort. In fact, the reward is often greater because of the effort required (within reason). The motivation for these adventures is intrinsic, and the journey is as important as the destination.

Adventure leaders must ensure all members of the group are appropriately prepared for the challenge ahead and stay safe and engaged. This involves having the ability to teach the physical skills required, ensuring the group has appropriate equipment for the conditions, and making judgement calls as conditions change. In addition, adventure leaders need to care deeply for the wellness of participants, watching for non-verbal cues that a participant might be suffering physically or mentally, and use wisdom to decide when and how to intervene, to improve participant satisfaction, and reduce the chances of a problem escalating.

III. RISKS IN HEALTH PROFESSIONS EDUCATION

Risks in teaching and learning include the fear of public speaking (common, though rarely acknowledged), the risk of embarrassment (from getting something wrong in front of others), and the risk of losing control (if you hand over too much control to the learners and can’t reign them back in). In the clinical environment, there’s a risk of learner harm and loss of empathy if we don’t prepare and support them adequately during their training, there’s a risk of losing clinical faculty if we make unreasonable requests of them, and there’s a risk of compromised patient outcomes if we don’t consider impact on patients due to our innovations, or lack thereof.

IV. IMPLICATIONS OF AN ADVENTURE METAPHOR

A. Academic Teaching

For academic faculty, an adventure mindset might encourage learning about teaching practices and experimenting with new techniques with some risk that they might not be successful. It also encourages innovations in teaching and scholarship to meet important social needs, even if these don’t seem like the most fruitful or safe endeavours from the perspective of traditional tenure and promotion metrics. If the academy would acknowledge the importance of unconventional approaches to scholarship and teaching to meet social needs, then it would need to reconsider how it evaluates performance.

B. Clinical Teaching

There’s a growing recognition that demonstrating vulnerability and empathy, can lead to more effective patient care and more effective clinical education, while also being more rewarding for preceptors. Many physicians have long since given up wearing a lab coat, and some are comfortable being on a first-name basis with medical trainees, as part of “an ethic of caring” which ensures learners feel safe and are better able to learn (Balmer et al., 2016). When teaching while providing clinical care, the clinician needs to think about how they are perceived by the patient, as well as by the trainee. It may be possible to balance the need to maintain credibility, while being vulnerable and modelling the clinical reasoning process for both student and patient, by exhibiting “Intellectual Candour” (Molloy & Bearman, 2019). Showing vulnerability and empathy might seem like a loss of formality, and this might feel risky, yet if this is a calculated risk, with opportunities for gain in the form of a more meaningful teaching experience and more impactful learning for students, then this might be a worthwhile adventure to embark on.

C. Underserved Populations

Some of the most medically underserved people in Canada (and globally), are rural and Indigenous peoples. If we are trying to train more healthcare providers to meet the needs of equity deserving groups, we need to consider how we are currently discouraging this. If cultural safety is not always experienced by Indigenous peoples (especially on their own, colonized lands), we need to keep cultural safety at the top of our list of priorities and we need to invest in it. If we currently provide a largely specialist curriculum which discourages rural generalist practice, we need to look at how we can make the curriculum more of a generalist curriculum. If we acknowledge that family practice has become less appealing as many family physicians now work in clinics with more limited scope, and less longitudinal relationships with patients (albeit more reasonable hours), then we should consider how to better support learners to consider full scope family practice.

In discussions about the characteristics of rural family physicians who provide full scope care, people often talk about ‘rational risk takers,’ as physicians who are more willing to accept risk, because they work in locations where timely access to specialist and subspecialist care is often not available, and working near or beyond the limit of their training is the alternate to seeing some patients not receive care at all. This is a form of calculated risk-taking and has recently been described as “Clinical Courage” (Konkin et al., 2020). If clinical courage is necessary for care providers serving our most underserved populations, then we need to encourage it, to reduce the healthcare provider maldistribution. This means ensuring that characteristics of clinical courage are embedded: when admitting students to our programs, in both our pre-clinical and clinical curricula, and in our assessments, for all learners.

V. CONCLUSION

Teaching and learning in the health professions should be fun, though a serious sort of fun. Our learners are now much more diverse than in the past, and they are advocating for needed changes in the healthcare system, while our clinicians are struggling. If we must innovate to sustain and improve what we do, then an adventure metaphor will encourage and inform how we approach this.

Health professions programs should ensure that working as a team, managing risks, and overcoming challenges with limited resources, are embedded within our curricula. We should also focus on intrinsic motivations of learners and faculty, and emphasise the importance of the journey, alongside the destination. Our systems need to ensure that clinical faculty have the capacity to care about the wellbeing of learners, alongside providing patient care. Embracing the metaphor of adventure should help invigorate our teaching and learning, and counteract burnout, while we work towards needed change in our health systems.

Notes on Contributors

The author conceived and wrote this manuscript.

Acknowledgement

The idea for this manuscript came from the author’s teaching philosophy and teaching dossier prepared for the Society for Teaching and Learning in Higher Education, 3M National Teaching Fellowship (2022 recipient). The idea has been shared at the Centre for Health Education Scholarship (CHES) Day of Scholarship (October 2022), the International Congress on Academic Medicine (ICAM, April 2023), and the Asia Pacific Medical Education Conference (APMEC, May 2023) and the idea has been improved and clarified through the critical feedback of peers at these meetings.

Funding

No funding was required for this study.

Declaration of Interest

The author has no conflict of interest, including financial, institutional, or other relationship that might lead to bias.

References

Balmer, D. F., Hirsh, D. A., Monie, D., Weil, H., & Richards, B. F. (2016). Caring to care: Applying Noddings’ philosophy to medical education. Academic Medicine, 91(12), 1618-1621. https://doi.org/10.1097/ACM.0000000000001207

Eva, K. W. (2022). An open letter to all stakeholders involved in medicine and medical education in Canada. Canadian Medical Education Journal, 13(4), 1-2. https://doi.org/10.36834/cmej.75549

Konkin, J., Grave, L., Cockburn, E., Couper, I., Stewart, R. A., Campbell, D., & Walters, L. (2020). Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): An international phenomenological study. BMJ Open, 10, Article e037705. http://dx.doi.org/10.1136/bmjopen-2020-037 705

Molloy, E., & Bearman, M. (2019). Embracing the tension between vulnerability and credibility: ‘Intellectual candour’ in health professions education. Medical Education, 53(1), 32-41. https://doi.org/10.1111/medu.13649

Office of the Surgeon General (OSG). (2022). Addressing health worker burnout: The U.S. Surgeon General’s advisory on building a thriving health workforce. US Department of Health and Human Services. https://www.hhs.gov/sites/default/files/health-worker-wellbeing-advisory.pdf

*Sean B Maurice
3333 University Way,
Prince George, BC,
Canada, V2N 4Z9
1-250-960-5443
Email: sean.maurice@unbc.ca

Submitted: 4 November 2023
Accepted: 20 November 2023
Published online: 2 April, TAPS 2024, 9(2),98-100
https://doi.org/10.29060/TAPS.2024-9-2/PV3165

John Norcini

Department of Psychiatry, SUNY Upstate Medical University, United States of America

I. INTRODUCTION

Over the past 25 years, the Asia Pacific region has seen striking growth in the scholarship of health professions education, and it is poised to continue its development. A window into the past and a glimpse of the future can be found in the meetings of the Asia Pacific Medical Education Conference (APMEC), which recently celebrated its 25th anniversary. To frame my personal observations, a word cloud was created using the titles of the plenaries, keynotes, and symposia of the 2003, 2004, and 2006 conferences and another was created using the titles from 2021, 2022, and 2023. When comparing these two clouds (an exercise akin to interpreting inkblots), three themes emerged: interprofessional education and practice (IPEP), the scholarship of teaching and learning (SoTL), and the growing role of technology.

Interprofessional Education and Practice. In the first three conferences, the most common word was ‘medical’ and in the last three it was ‘education’. This parallels developments in the field, which started with a focus entirely on medical education, expanded to all the health professions, and in its most recent iteration, turned to interprofessional education. The reason for this latest development is research showing that interprofessional practice results in better patient outcomes, improved efficiency of care, and increased satisfaction among providers (Reeves et al., 2017).

One of the biggest barriers to IPEP is social closure, defined by Mackert (2012) as the “process of drawing boundaries, constructing identities, and building communities in order to monopolize scarce resources for one’s own group, thereby excluding others from using them.” (Mackert, 2012). Each profession has an educational model that encompasses as much of practice as possible, and they compete over ownership at the boundaries. This limits interprofessional cooperation and the opportunity for joint training.

Social closure has been institutionalised through the regulatory processes (i.e., accreditation and licensure/registration) used in many countries. These fix the boundaries of the professions and the nature of training and practice. Regulation ensures initial competence but makes it challenging to develop shared competencies across the professions. Moreover, there are few regulatory requirements for keeping up with changing practice and even fewer ways to acknowledge the acquisition of additional competencies after formal training.

Digital badges or micro-credentials are one way to approach the issue of social closure.  They are circumscribed credentials based on shorter educational experiences followed by assessment. They can be part of existing broad educational and regulatory processes, complement them, or replace them in part. These credentials can be applied across professions and throughout careers.

Micro-credentials can support the development of IPEP by increasing access and shifting the focus from what the professions can do, to what patients and healthcare systems need. The fact that different professions experience the same educational process leads to comparability across providers regardless of discipline, less siloed regulation, and increased interprofessional collaboration. Furthermore, it offers a pathway for practitioners who seek to upgrade their skills or acquire new competencies.

The scholarship of teaching and learning. The second theme that emerged from a comparison of the word clouds was the scholarship of teaching and learning (SoTL). ‘Curriculum’ and ‘assessment’ were prominent in the first APMEC conferences, but they vanished recently, with ‘learning’, ‘scholarship’, and ‘educator’ being more prominent. In my view, this shift signifies the growing role of SoTL.

The goal of SOTL is to improve student learning by identifying effective teaching practices and disseminating those practices. It is a relatively new field of scholarship that has nine attributes: “committed engagement in action, critique-based, disciplinary, context-oriented, critical enquiry process, continuous deep reflection, dynamic process, shared publicly, and learning focused.” (Mirhosseini et al., 2018).

A recent edition of the Asia Pacific Scholar exemplifies this work (Lee & Norcini, 2023). It included studies that addressed topics such as community based interprofessional education, cultural awareness training in the emergency room, approaches to vaccine hesitancy, innovative oral exams for occupational therapy students, and coaching programs for faculty members.

Technology. The third theme that emerged from the comparison of the word clouds was technology.  ‘eLearning’, prevalent in the early days of the conference, has disappeared to be replaced by ‘technology’. In my view, this signifies its growing role in health professions education and assessment. To pursue this further, Bard (Google’s AI chatbot) was asked, “What effect will technology have on education in the health professions?” Below is Bard’s response, edited for British spelling and for length by removing examples.

“Technology is already having a significant impact on education in the health professions, and this trend is only going to accelerate in the coming years. Here are some of the key ways in which technology is transforming health professions education

• Increased use of e-learning and simulation provides students access to high-quality educational resources and experiences, regardless of location or time constraints.
• Technology can be used to create personalised learning experiences for each student.
• Technology can be used to facilitate interprofessional collaboration between students and healthcare professionals from different disciplines.
• Technology can be used to collect and analyse data on student learning and performance.

Overall, technology is making health professions education more accessible, personalised, and effective.

Here are some of the potential benefits of using technology in health professions education:

• Improved access to education: Technology can help to break down barriers to access to education, such as distance, time constraints, and financial resources.
• Increased student engagement: Technology can be used to create more engaging and interactive learning experiences.
• Improved learning outcomes: Technology can be used to personalise learning, provide feedback, and track student progress.
• Better preparation for practice: Technology can be used to simulate real-world clinical scenarios and help students to develop the skills they need to be successful practitioners.

However, there are also some potential challenges associated with the use of technology in health professions education, such as:

• Cost: Technology can be expensive to purchase and maintain
• Digital divide: Not all students have equal access to technology resources
• Technical challenges: Technology can be complex and difficult to use
• Quality control: It is important to ensure that technology-enhanced learning resources are high-quality and effective

Overall, the benefits of using technology in health professions education outweigh the challenges. However, it is important to use technology thoughtfully and strategically to ensure that it is used to enhance learning, not replace it.” (Bard, 10/30/2023)

This is an impressive performance by Bard, and it offers a small preview of what technology may do. The ideas are not novel, but a wide range of thinking was summarised in a systematic fashion within seconds. This is just the beginning for generative artificial intelligence but it is clear that technology will reshape educational practice and scholarship. It also raises important questions about how we interact with it going forward.

II. SUMMARY

APMEC’s history provides a means of describing the dramatic growth in health professions education in the Asia Pacific region. The past 25 years have seen the focus of research expand from its start in medical education through all the health professions to IPEP. To drive this growth, new forms of scholarship have taken root. With its strong emphasis on context, SoTL enhances the relevance of this research to the cultures and practices of the region. Finally, technology, and our relationship with it, will have profound effects going forward. Taken together, these trends lay the groundwork for future work that will serve the needs of the region and have sizeable influences beyond it.

Note on Contributor

John Norcini wrote the paper.

Funding

No funding was involved.

Declaration of Interest

There are no conflicts to declare.

References

Lee, S. S., & Norcini, J. (2023). Celebrating excellence in the scholarship of teaching and learning. The Asia Pacific Scholar, 8(2), 1-3. https://doi.org/10.29060/TAPS.2023-8-2/EV8N2

Mackert, J. (2012). Social Closure. Oxford University Press.

Mirhosseini, F., Mehrdad, N., Bigdeli, S., Peyravi, H., Khoddam, H. (2018). Exploring the concept of scholarship of teaching and learning (SoTL): Concept analysis. Medical Journal of The Islamic Republic of Iran, 32(1), 553-560. https://doi.org/10.14196/mjiri. 32.96

Reeves, S., Pelone, F., Harrison, R., Goldman, J., & Zwarenstein, M. (2017). Interprofessional collaboration to improve professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 6. https://doi.org/10.1002/14651858.CD0000 72.pub3

*John Norcini
Upstate University Hospital
750 East Adams Street
Syracuse, NY 13210
Email: John.norcini@gmail.com

Submitted: 30 June 2023
Accepted: 19 October 2023
Published online: 2 April, TAPS 2024, 9(2), 95-97
https://doi.org/10.29060/TAPS.2024-9-2/PV3075

Gabriel Tse Feng Chong^1,2

¹Singapore Armed Forces HQ Medical Corps, Singapore; ²Dental Specialist Accreditation Committee (Dental Public Health), Singapore

There is growing awareness of the need to include humanities in educating dental students at the undergraduate/pre-doctoral level (Marti et al., 2019). However, there appears to be no literature discussing or advocating the inclusion of humanities for the training of dental specialists. Dental Public Health (DPH) is one such dental specialty where its trainees and practitioners would benefit from an inclusion of humanities in its pedagogy.

This author opines that exposure to humanities (which includes, but is not limited to, literature – both fiction and non-fiction, art, history, narrative dentistry/medicine, philosophy, ethics, and medical anthropology) that touch on dental themes can make a DPH trainee/practitioner more rounded; able to empathise better with the individuals that his/her policies and programs would affect; become even more persuasive in health promotion efforts; and more articulate in their advocacy efforts with stakeholders and policy makers.

Unfortunately, the curriculum of most DPH training programs (in English speaking jurisdictions) do not include humanities apart from the inclusion of ethics in North American programs. Perhaps the roots of this problem can be traced back to the dental undergraduate/pre-doctoral level where the typical training is predominately focused on biomedical subjects. The result is “few dental schools have implemented humanities in their dental education” and where humanities are taught, ethics tend to form the bulk (Marti et al., 2019). At the postgraduate specialty-training level, this traditional segregation between what are considered ‘sciences’ on one hand, and ‘humanities’ on the other hand, are already ingrained for most dental specialties. However, the DPH curriculum is different from the sister dental specialties because the trainee is required to understand for instance: sociology, health-related behaviors, the interactions of social, cultural and political variables (including age, gender, socioeconomic status, culture, religion, ethnicity and globalisation) on public health, health inequities, and the provision of health services. In essence, the DPH curriculum aims to re-orientate the trainee from a biomedical model of care to a biopsychosocial model of care. As such, the DPH curriculum is a natural starting point for the inclusion of humanities in the training of dental specialists.

There are some foreseeable barriers to implement humanities in the DPH training curriculum – (i) the possible lack of DPH educators and practitioners who are well-versed or at least comfortable with humanities and this itself may be a barrier to even commencing the addition of humanities into the pedagogy, and (ii) finding the time and space to include humanities into the voluminous curriculum that the DPH trainee is expected to cover in a relatively short amount of time. One suggestion to resolve the former barrier is cross-disciplinary training, where dental and/or public health schools can reach across to educators and researchers in the humanities departments to co-develop the DPH-humanities curriculum and training materials. The latter barrier can perhaps be tackled by infusing readings and discussions on humanities into the DPH curriculum that already require the trainee to adopt a biopsychosocial approach to healthcare and where humanities would be natural additional skillsets for inclusion in the DPH trainees’/practitioners’ toolbox.

Oral health inequities exist in most, if not all, societies. The burden and resultant impact of dental caries is largely borne by those who are disadvantaged and underserved. This is true even of an affluent country in Asia-Pacific like Singapore with a highly educated populace with very good healthcare system, infrastructure, and policies. Singapore enjoys (i) an universal community water fluoridation program covering 100% of Singapore’s population, (ii) public health education to increase awareness and health literacy by actors, such as, the Ministry of Health (MOH) and Health Promotion Board (HPB), (iii) free dental care to school children up to 18 years of age, and (iv) an extensive network of dental clinics in the private and public sector (Chong & Tseng, 2011). Despite all these benefits, the burden of poor oral health is mainly carried by members of lower socioeconomic groups and certain racial groups (Chong & Tseng, 2011).

Humanities can also challenge the lens through which a DPH trainee/practitioner views oral health problems. For instance, even the current epidemiological trends of dental caries was not always the case. For example, if we were to go back in time to about the late 18th century, dental caries in Europe was largely a disease of the affluent. This is even mentioned in a gastronomical literature text ‘The Physiology of Taste’, written by Brillat-Savarin (published in 1825), in which the author describes the poor oral health of his fellow diners. He writes “what then if the mouth is neither fresh nor pretty? And what shall be said of those monstrous chasms which open up to reveal pits that would seem bottomless, if it were not for the sight of shapeless, time-corroded stumps?” (Chong, 2012).

What caused the epidemiological shift such that dental caries was no longer a disease of the affluent but became one of the poor? This is because until about the late 18^th century, sugar was not yet widely available to the masses for consumption frequently and/or in large quantities so as to cause widespread decay. For example, in England, the annual consumption of sugar per capita increased from almost zero in the 17^th century to 1.8kg in 1704 to 8.2kg in 1800, and finally to 40.8kg by the mid-19^th century (Chong, 2012). Several factors have been identified as the causes of increased consumption of sugar during this period: increased disposable income due to the industrial revolution; the availability of processed foods and beverages; and the change in dietary habits to add sugar as a sweetener to tea and coffee (Chong, 2012). 

This historical trend is important for the modern DPH trainee/practitioner because it approximates ecological studies and supports our modern understanding that the intake of dietary sugars is the most important risk factor for developing dental caries. This should focus DPH trainees’/practitioners’ efforts to tackle the Social Determinants of Health (including the commercial determinants, such as the health risks posed by the sugar and fast-food industries). Furthermore, the 180-degree shift in the epidemiology of dental caries should serve as a reminder that what is the norm of today can be changed drastically in the future, and therefore improvements at a societal-level are possible.

Despite being the most prevalent chronic disease condition globally, dental caries is seldom reported in the news save for the rare occasions where it is extremely headlines worthy, such as the case where a 12-year old American boy (Deamonte Driver) passed away because of an untreated tooth abscess arising from dental caries (Otto, 2017). In this regard, DPH trainees and practitioners can utilise the humanities (in the form of literature, narrative dentistry, and art) as useful media to showcase the plight of the poor and the injustice of oral health inequities. This is needful because sometimes key stakeholders and policy makers (who usually do not have healthcare backgrounds) may not quite comprehend or relate to quantitative data, whereas the narrative aspects such as the description of the individuals’ experience can be very emotive to nudge those stakeholders and policy makers towards the right direction. Editors and reporters of traditional media channels are more likely to publish articles and editorial pieces that are deemed ‘headlines worthy’ with a compelling story to tell.

To highlight the potential power of humanities in telling a story, the author would like to quote a passage from the novel ‘Les Miserables’ by Victor Hugo (originally published in 1862), that depicts the emotional and physical pain of those who were forced to sell their teeth out of dire economic circumstances; which was a fairly common practice in European society of that time.

Excerpt from Les Miserables (Hugo, 1982, p. 177 – 178):

He was an itinerant dentist selling sets of false teeth, opiates, powders, and elixirs… seeing Fantine laugh, the dentist cried:

‘You’ve got a fine set of teeth, my lass. If you’d care to sell me your two incisors I’ll pay you a gold napoleon for each.’

‘What are my incisors?’

‘Your two top front teeth.’

‘How horrible!’ exclaimed Fantine.

‘Two napoleons,’ grumbled a toothless old woman standing near. ‘She’s in luck!’

Fantine fled, covering her ears to shut out the man’s hoarse voice as he shouted after her:

‘Think it over, my girl. Two napoleons are worth having. If you change your mind you’ll find me this evening at the Tillac d’argent.’…

When Marguerite entered Fantine’s room next morning… she found her seated cold and shivering on her bed… and it seemed that she had aged ten years overnight.

‘Lord preserve us!’ cried Marguerite, ‘What’s the matter with you?’

‘Nothing is the matter with me,’ said Fantine, ‘I’m happy. My baby isn’t going to die of that dreadful disease for lack of medicine.’

She pointed to two napoleons that lay gleaming on the table.

‘A fortune,’ murmured Marguerite. ‘A fortune! Where did you get them?’

‘I earned them,’ said Fantine.

She smiled as she said it, and the candle lighted her face. It was a bloodstained smile. There were flecks of blood at the corners of her mouth and a wide gap beneath her upper lip.  

Notes on Contributors

The author conceived the ideas stated in this personal review article and wrote the manuscript.

Funding

The author declares that no financial support was received for this personal view article.

Declaration of Interest

The author declares that there is no potential conflict of interest.   

References

Chong, G. T. F. (2012). Jean-Anthelme Brillat-Savarin’s 1825 treatise on the mouth and ingestion. Singapore Dental Journal, 33(1), 31-36. https://doi.org/10.1016/j.sdj.2012.10.002

Chong, G. T. F., & Tseng, P. (2011). A review of the uses of fluoride and outcomes of dental caries control in Singapore. Singapore Dental Journal, 32(1), 14-18. https://doi.org/10.1016/ S0377-5291(12)70011-1

Hugo, V. (1982). Les Miserables. Penguin Classics.

Marti, K. C., Mylonas, A. I., MacEacher, M., & Gruppen, L. (2019). Humanities in predoctoral dental education: A scoping review. Journal of Dental Education, 83(10), 1174-1198. https://doi.org/10.21815/JDE.019.126

Otto, M. (2017, June 13). How can a child die of toothache in the US? The Guardian. https://www.theguardian.com/inequality/2017 /jun/13/healthcare-gap-how-can-a-child-die-of-toothache-in-the-us

*Gabriel Chong
Singapore Armed Forces HQ Medical Corps,
701 Transit Rd,
Singapore 778910
Email: g.chong@mail.com

Submitted: 6 May 2023
Accepted: 12 September 2023
Published online: 2 April, TAPS 2024, 9(2), 92-94
https://doi.org/10.29060/TAPS.2024-9-2/PV3054

Bhuvan KC¹ & Pathiyil Ravi Shankar²

¹School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Australia; ²IMU Centre for Education, International Medical University, Malaysia

I. INTRODUCTION

Learning spaces can be physical, virtual, or hybrid spaces where students engage with the learning material and interact with peers and facilitators. Traditionally, learning spaces used to be classrooms, lecture halls, laboratories, and libraries and would include a teacher and students working inside a fixed space using a blackboard/whiteboard, PowerPoint projector, boards, and flexible/fixed seating arrangements.  With the advancement in educational methodologies and incorporation of technology and newer applications, learning spaces now include simulated laboratories, online learning platforms, and virtual and augmented reality-based platforms. Using virtual spaces students can interact and learn from wherever they are living/staying.

The healthcare sector has a demand for personalised and precision medicine, teleconsultation, artificial intelligence (AI)-assisted devices and programs, health/clinical applications, health informatics, and robotics along with the need for healthcare and clinical services and medicines. However, there has not been enough research and discussion around the built-in environment i.e., learning spaces in health sciences education and the activities of teaching and learning (Temple, 2007). Against this backdrop, we need to examine how students use learning spaces to interact and engage with the learning material in our current environment and think about how we can optimise the learning spaces for active learning and make them more impactful and future-ready.

II. LEARNING SPACES

Learning spaces in health sciences must consider the unique needs of these subjects in terms of teaching and learning activities, student engagement, and hands-on sessions. Learning spaces design are domain specific and must cater to the teaching and learning needs of the discipline. Designing learning spaces for health sciences is challenging. Learning space can have a significant impact on teaching and learning experiences. A well-designed learning space can help students in many ways:

• It can promote student engagement, is always inviting and comfortable, and stimulating for students. They can sit together and discuss a case or work on a project (Wilson & Randall, 2012).

• A nice and comfortable multi-purpose space can help students engage in project work. They can move the seating to suit their group’s needs, write on the table surface, and whiteboards and discuss, charge their laptops, and use the internet to interact in virtual spaces. Interactive classrooms could make instruction more efficient and effective. More research is needed on the effect of learning space design on students’ engagement and the outcomes of teaching and learning. Health sciences students engage in formal and informal learning, peer support and discussion, clinical case practice and use different diagnostic equipment.

• A well-designed and well-equipped classroom can allow teachers to design workshops and activities that engage students in groups. A flexible learning space can help teachers be more creative and innovative in their approach. Flexible learning spaces provide pedagogical opportunities and support innovative practices that are not easily provided by traditional learning spaces (Benade, 2019). Health Sciences schools must think of ways to design and use learning spaces to promote active learning and help students learn clinical decision-making, required skills, therapeutic reasoning, clinical examinations, and other important practical skills.

• A well-designed learning space can promote collaboration and enhance creativity among the students. A learning space where students can interact face to face, bring their devices, and use tables, boards, and other tools will promote better collaboration and learning. However, one significant challenge is to have enough collaborative learning rooms to accommodate students; multipurpose tables, boards, and other teaching aids and devices are important given that space is at a premium, especially in urban centres (Jamieson, 2003; Van Joolingen et al., 2005). Hybrid learning spaces may partly address this problem.

III. DESIGNING A COLLABORATIVE LEARNING SPACE

To design a collaborative learning space for health sciences we must examine how learning occurs. Active learning plays an important role. There is extensive use of technology in learning. We use interactive whiteboards, create personalised learning environments, wireless networks and the internet, interactive software such as PollEverywhere, Slido and MyDispense, games, applications, etc. to engage with learners in a physical, virtual, or hybrid environment. So, our first consideration is to have a learning space that is flexible, accommodative, supports technologies used for teaching and learning, and is sustainable. Some steps that we can include in our planning and design of learning space can be:

1) Define the learning objectives: The first key consideration while designing a learning space is to look at the programme learning objective. We need to evaluate what students want to achieve in terms of learning outcomes and what skills do they need to acquire for that programme/subject. For campuses running multiple programmes collaboration across the discipline is needed during the planning stage to look at learning spaces that can work for multiple disciplines. Health sciences students gain specialised skills for patient care, including clinical competence, interdisciplinary collaboration, ethics, cultural sensitivity, and patient communication.

2) Consider the size and layout: The learning space must have adequate room to fit all the pupils in the group, necessary furnishings, and equipment. Consider the programme’s enrolment and the activities that the learners will take part in. The layout should encourage student collaboration and active learning.

3) Utilise technology: Technology plays a significant role in modern-day learning. Our subjects/programmes are managed via online platforms like Moodle, CANVAS, Blackboard, etc. Post-COVID Universities/ Schools are running their programmes in a hybrid fashion. Integrating the latest technology, especially the information and communication technology (ICT) based applications and built-in system seems to be vital when we deliver our programmes through online platforms. Tests are run via online quizzes and electronic assessment platforms.

4) Flexibility in learning spaces: Flexibility is the key consideration when designing a learning space in modern classrooms. These learning spaces must be customisable to accommodate the various learning requirements of the students in a flexible learning environment.

5) Optimise lighting and acoustics: Lighting and acoustics are critical factors that can impact learning. It is important when we want to use a virtual environment for immersive learning or play a video to demonstrate 3D- anatomical illustrations. Ensure the learning space has adequate lighting, and acoustics are optimised to minimise noise levels and distractions.

6) Emphasise sustainability: When designing the learning space, sustainability should be a top priority. To lessen the environmental impact and foster a healthy learning environment, incorporate sustainable materials and designs.

7) Encourage collaboration: Active learning requires collaboration, which is a crucial component. Think about including group tables, breakout rooms, and collaborative learning spaces.

8) Customisation of learning spaces: Learning spaces (formal or informal) must be accommodative. For example, a learning space must fit multiple activities like workshops, lectures, problem-based learning, small group discussions, simulation activities, etc. Thus, having flexible elements like collapsible walls, movable desks and chairs, computers on wheels, and foldable furniture and equipment will be ideal from a customisation perspective.

IV. CHALLENGES IN DESIGNING LEARNING SPACES

Learning space design is challenging especially for health and medical sciences programmes because of the specialisation and the complexities of the curriculum and its requirements. It is even more challenging for resource limited settings where universities and schools are struggling to deliver high quality teaching and learning even in traditional environments. These challenges are manifold:

1) Health sciences curricula are content-rich but traditionally taught didactically. Designing learning spaces, crucial for activities like problem-based learning, clinical skill practice, and immersive anatomy learning, presents challenges due to their specialised requirements. Altering spaces to these needs is complex.

2) Keeping the learning spaces human centred is another challenge given the rapidly changing teaching and learning delivery methods brought about by information technology. The pedagogy must be the priority and technology must support it and make it more efficient.

3) Designing learning spaces involves multiple priorities. There are elements like curriculum/content requirement, disability access, collaborative learning, and use of technology. Creating a learning space balancing these elements is a challenge, especially for educational institutions in low resource settings.

4) Designing adaptable learning environments that embrace evolving technologies and teaching methods is complex. A versatile collaborative space, equipped with tables, chairs, digital tools, and virtual platforms, must serve diverse students and activities. This challenge is intensified in resource-limited settings, where maintaining physical and virtual elements, costly online resources, and internet quality pose additional hurdles.

V. CONCLUSION

Learning spaces need proper focus. Health science programs are undergoing major structural transformations. Thus, our learning space must be coordinated with active learning pedagogy and philosophy. While designing learning spaces we must consider flexibility, comfort, technology, collaboration, and safety to build a collaborative and futuristic learning space that allows students to engage with their learning content and achieve the required learning outcomes.

Notes on Contributors

BKC contributed to the conceptualisation of the manuscript, wrote the first draft, revised the subsequent draft, and contributed to the final draft. PRS contributed to the conceptualisation of the manuscript and critically revised the first draft. He contributed to the subsequent revision and finalisation of the manuscript.

Funding

The authors did not receive any funding for this article.

Declaration of Interest

The authors would like to declare that they do not have any conflict of interest.

References

Benade, L. (2019). Flexible learning spaces: Designed for inclusion? New Zealand Journal of Education Studies, 54(1), 53-68.

Jamieson, P. (2003). Designing more effective on‐campus teaching and learning spaces: a  role for academic developers. International Journal for Academic Development, 8(1-2), 119-133. https://doi.org/10.1080/1360144042000277991

Temple, P. (2007). Learning spaces for the 21st century: A review of the literature. Retrieved from https://www.advance-he.ac.uk/knowledge-hub/learning-spaces-21st-century

Van Joolingen, W. R., de Jong, T., Lazonder, A. W., Savelsbergh, E. R., & Manlove, S. (2005). Co-Lab: Research and development of an online learning environment for collaborative scientific discovery learning. Computers in Human Behavior, 21(4), 671-688. https://doi.org/10.1016/j.chb.2004.10.039

Wilson, G., & Randall, M. (2012). The implementation and evaluation of a new learning space: a pilot study. Research in Learning Technology, 20(2), 14431. https://doi.org/10.3402/rlt.v20i0.14431

*Bhuvan KC
Discipline of Pharmacy, School of Clinical Sciences,
Queensland University of Technology,
2 George Street, Brisbane, Qld, Australia
Email: kc.bhuvan@qut.edu.au

Submitted: 12 June 2023
Accepted: 2 August 2023
Published online: 2 January, TAPS 2024, 9(1), 58-60
https://doi.org/10.29060/TAPS.2024-9-1/PV3064

Rintaro Imafuku, Chihiro Kwakami, Kaho Hayakawa & Takuya Saiki

Medical Education Development Center, Gifu University, Japan

I. GLOBALISATION IN EAST ASIA

Globalisation, a complex and multifaceted phenomenon, encompasses not merely an increasing people’s mobility and economical trades, but sometimes, their political and ideological struggles, and cultural identity formation issues, too. While North American and European countries have had a long history of accepting a large number of immigrants, while Asia experienced 74% growth of hosting international migrants from 2000 to 2020, which was most remarkable (McAuliffe & Triandafyllidou, 2021). For example, Japan’s proportion of immigrant population increased from 1.3% in 2000 to 2.2% in 2021, with Chinese migrants constituting the largest group, followed by Vietnamese, Koreans, Filipinos, and Brazilians. Similarly, in 2021, immigrants accounted for 3.4% of Korea’s total population in 2021, compared to 0.5% in 2000. These immigrants came from China, Vietnam, Thailand, Uzbekistan and other countries (McAuliffe & Triandafyllidou, 2021).

These changes in culture and population dynamics have significantly impacted on people’s health and healthcare in East Asia. One of the most challenging issues in such globalised Asian societies is managing intercultural communication between health professionals and migrant patients. Given this context, as languages become a key issue, health professionals are expected to accommodate patients’ communication needs. Moreover, while responding to the rapid internationalisation, health professionals in Asia need to embrace the belief that individuals are members of multiple, diverse, local and non-local networks, thus promoting global citizenship. In fact, the question is: How should Asian health professionals address the intercultural communication situations in healthcare?

II. COMMUNICATION STRATEGIES IN INTERCULTURAL SETTINGS

Many previous linguistic studies have discussed that in Asia, English serves as the lingua franca – a common language adopted among people who do not share a native language. Singaporeans, for instance, use English as an intra-national communication medium, while in East Asian countries, somewhat different contexts would have existed, particularly in relatively ‘monolingual’ speech communities. Given that, most immigrants in East Asia are not native English speakers, in many cases where English does not function as their medium of communication for them. In other words, English is not the sole solution for intercultural communication issues, particularly in East Asian countries. However, some health professionals in Japan viewed English as the panacea for intercultural communication issues, regardless of the patients’ native language, which highlighted the need to consider another communication management strategy in an intercultural setting (Imafuku et al., 2022).

A host country’s plain language, which is defined as clear and concise language accommodation, can be an effective medium of communication (Imafuku et al., 2022). For example, a national survey in Japan demonstrated that many immigrants could understand simple Japanese in daily life, even though their proficiency was limited. Assuming that the speakers tailor their communication to the interlocutors’ language proficiency levels and cultural backgrounds, plain language in spoken communication can be achieved by using short and simple sentences, active voice which emphasises the doer of an action, and personal pronouns which makes it easier for the listeners to picture themselves in the message. Furthermore, speakers must avoid ambiguous expressions and fillers that fill pauses with words, such as “um”, “ah”, “er” and so forth. Visual aids, such as charts, pictures and writing down messages, are also helpful for listeners to process the information in conversations.

Language translation devices, application software, and artificial intelligence (AI) technologies can be useful resources for managing intercultural communication in healthcare. For example, ChatGPT has the potential to assist and enhance health communication in hospitals. In particular, as these AI tools rely on patterns in huge amounts of existing text data, they excel at automating routine tasks, generating document summaries and translating simple texts of factual information. However, the users also need to be aware of the potential drawbacks of these tools, which may lack the ability to interpret patients’ communication signals by patients, such as tone, prosody, and non-verbal cues, potentially resulting in misunderstandings and miscommunications, especially with immigrant patients. This absence of human interaction, including the consideration of patients’ thoughts, emotions, patience, and empathy, emphasises the need for health professionals to critically evaluate and appraise the use of these AI tools for use in intercultural communication (Santandreu-Calonge et al., 2023).

In addition to the linguistic and sociolinguistic aspects, different cultural values and religious beliefs may create barriers in intercultural communication between providers and patients (Zhao, 2023). For example, patients may have diverse perspectives on confidentiality, gender, trust in health professionals and privacy concerns, which greatly impact on interactions in healthcare. Zhao (2023) suggests that patients with certain cultural backgrounds view the family as a collective unit, and would trade off their privacy for family support. However, sharing patients’ information with their family members can pose an issue of confidentiality issues for health professionals. In this case, the patients’ beliefs about family support and ties are closely intertwined with confidentiality in healthcare. In other words, effective intercultural communications will be enhanced by health professionals gaining a better socio-cultural understanding of immigrant patients.

III. MOVING FORWARD: EDUCATIONAL DEVELOPMENT

Educational development is key to effectively addressing the challenges faced by health professionals in East Asia’s globalisation wave. English has been taught as an ‘international academic language’ in Asian medical schools and serves as the medium of instruction in certain countries and Asian institutions. In other words, English can be a means of facilitating intercultural communication in Asian healthcare, particularly for foreign visitors from Western countries.

Additionally, for more successful language accommodation, plain language should be systematically taught in health communication courses in East Asia’s medical education. A growing body of evidence from Western countries indicates that incorporating plain language training into medical education has positive implications for oral and written communication skills. By using the host country’s plain language for practical training of intercultural communication in the curriculum, medical students in East Asia should be given more opportunities to interact with migrant citizens with different cultural backgrounds.

In addition to the effective use of plain language as an option of communication management strategies, this opportunity will also broaden the students’ worldviews and cultural understanding in the current globalised societies. Specifically, our institution, Gifu University, has incorporated learning opportunities through interactions with migrant citizens from Vietnam, Philippines and Brazil into first year medical education. This can serve as a springboard to cultivate the medical students’ global citizenship by learning diverse cultural values through conversations with the migrants in Japan.

Translation software and AI technologies are increasingly being utilised in the intercultural communication settings. Although these devices and tools are helpful, they can also be a double-edged sword for healthcare professionals as communicators. Health professionals and educators should recognise that human interaction is the foundation of communication. Relying excessively on such tools without critical evaluation may cause serious communication problems with migrant patients and their family members. In Japan, information technology has been newly set as a learning objective in the 2022 revision of the Model Core Curriculum for Medical Education (Medical Education Model Core Curriculum Expert Research Committee, 2022). Further educational development is necessary to train health professionals to fully understand the principles of the information science and technology, and effectively apply them in clinical practice. Specifically, in the field of health communication education, the educators must address the challenges posed by rapid globalisation by developing programs that enable learners to understand the advantages and disadvantages of AI-mediated communications and effectively utilise the information technologies in the intercultural settings.

Finally, from the perspective of medical education research, more internationally published research on intercultural health communication from Asian countries is necessary. The rich descriptions and analysis of the interactions between healthcare providers and migrant patients in the current globalised Asian countries can offer different perspectives on medical education for an international readership. Additionally, for further educational development, it would be worthwhile to explore AI-mediated communication in intercultural situations, as this is a relatively new research area.

Notes on Contributors

Rintaro Imafuku contributed to this manuscript’s conceptualisation, wrote its first draft, and revised its subsequent draft. Chihiro Kawakami, Kaho Hayakawa and Takuya Saiki contributed to the conceptualisation and critically revised the first draft. All the authors discussed and contributed to the final manuscript.

Funding

This study was supported by the JSPS KAKENHI [Grant number: 20K10374].

Declaration of Interest

The authors declare no competing interests.

References

Imafuku, R., Nagatani, Y., & Shoji, M. (2022). Communication management processes of dentists providing healthcare for migrants with limited Japanese proficiency. International Journal of Environmental Research and Public Health, 19(22), Article 22. https://doi.org/10.3390/ijerph192214672

McAuliffe, M., & Triandafyllidou, A. (2021). World migration report 2022. International Organization for Migration (IOM). https://publications.iom.int/books/world-migration-report-2022

Medical Education Model Core Curriculum Expert Research Committee. (2022). Model core curriculum for medical education in Japan 2022. Ministry of Education, Culture, Sports, Science and Technology. https://www.mext.go.jp/content/20230315-mxtigaku -000026049_00003.pdf

Santandreu-Calonge, D., Medina-Aguerrebere, P., Hultberg, P., & Shah, M.A. (2023). Can ChatGPT improve communication in hospitals? Profesional de la información, 32(2), Article e320219. https://doi.org/10.3145/epi.2023.mar.19

Zhao, X. (2023). Challenges and barriers in intercultural communication between patients with immigration backgrounds and health professionals: A systematic literature review. Health Communication, 38(4), 824–833. https://doi.org/10.1080/10410236.2021.1980188

*Rintaro Imafuku
1-1 Yanagido Gifu, Gifu, Japan
+81-58-230-6469
Email: imafuku.rintaro.f9@f.gifu-u.ac.jp

Submitted: 19 February 2023
Accepted: 10 July 2023
Published online: 3 October, TAPS 2023, 8(4), 50-52
https://doi.org/10.29060/TAPS.2023-8-4/PV3007

Nathasha Luke¹, Reshma Taneja¹, Kenneth Ban², Dujeepa Samarasekera³ & Celestial T Yap¹

¹Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Health Professional Education has considerably evolved over the years. Traditional classroom teaching has shifted to blended learning modalities, and clinical teaching has embraced virtual reality and simulation-based learning.

Education is poised for another major change with the development of artificial intelligence (AI) models that can emulate human-like intelligent behaviour, particularly in the field of large language models (LLM) that are capable of generating text in response to user input. There has been remarkable progress in the development of these models, with each iteration having an increasing ability to generate human-like responses to user input.

In November 2022, Open AI released ChatGPT. This marked a major milestone in the ability of LLMs. This leap in performance was driven in part by the training of the model on large text datasets from various sources such as books, articles, and websites. It was combined with supervised learning and reinforcement learning to fine-tune the model based on human feedback about the quality of the output. This was further augmented by the release of GPT-4, a further advanced version in early 2023.

A study demonstrated that ChatGPT was able to pass or preform at near parsing threshold in the United States Medical Licensing Examination (USMLE) (Kung et al., 2023). Also, ChatGPT passed a law entrance examination at a level equivalent to a C+ grade (Kelly, 2023). These studies highlight the potential of modern LLMs to impact education.

Despite its impressive performance, LLMs have limitations. These caveats notwithstanding, when educators and students are aware of the capabilities and limitations, LLM tools could provide opportunities to improve the way we teach and the way students learn. More evidence is needed to depict a specific model as if how this technology could be incorporated. This article particularly focuses on capabilities and limitations of LLMs in the context of medical education with suggestions on how this technology might be used. There is a huge scope for discussion on the impact of LLMs in various dimensions of medical education. However, we limit this discussion to commonest domains pertaining undergraduate medical education.

Being widely available and accessible to educators and students around the world including resource poor settings, LLMs promote equity in medical education.  Certain educational institutes have customised learning platforms to support student learning while such amenities are not accessible in resource poor settings.  On the contrary, the technology of LLMs could at least partially counterbalance such shortages promoting equity.

In addition, Universities in resource-poor settings often find inadequate number of educators as a barrier to implement new teaching strategies and curriculum reformation, particularly with the shifting paradigms to competency based medical education (Ramanathan et al., 2022). Effective incorporation of LLM tools could ease their workload to some extent, providing more time to explore new teaching pedagogies and scope for curricular reformations.  

LLM tools are being adopted in medical education, and assistive in both clinical and non-clinical settings, as discussed below. In non-clinical settings, the following are some areas where LLMs are helpful.

From an educator’s perspective, LLM tools are helpful in generating summaries, quizzes, and flashcards to make the learning interesting.

From learners’ perspective, LLM tools can generate customised information within a short span of time. For example, we may ask the LLM tool to answer a question ‘at a level of a medical student’ or ‘at the level of a resident’, to generate distinct responses. This will assist students in self-learning and understanding difficult concepts. LLM tools are also helpful in generating mnemonics, poems, and flashcards. Students who are not native English speakers will have the added advantage of AI tools being assistive in improving language skills. 

Additionally, LLMs are assistive tools in many stages of research including design and development, implementation, literature survey and data analysis.

There is emerging literature illustrating capabilities of LLMs as useful tools in medical practice (Lee et al., 2023). Though there aren’t many publications evaluating implications of current LLM technology in the domain of clinical education per -se, this technology is likely to be helpful in the development of skills such as history-taking and doctor-patient communication. Customized chatbots have been used by some medical schools to improve history-taking skills. Development of such tools are not affordable in resource-poor settings. LLM tools such as ChatGPT are not capable of ‘acting’ as a model patient to practice history taking. However, they can guide students to formulate relevant questions for effective history-taking in specific scenarios. Students should not be encouraged to use AI tools as the sole reference to guide the task, rather use it as an adjunct to ones’ thought process. For instance, if a student encounters a patient with palpitations, he or she should brainstorm based on theoretical knowledge to formulate relevant questions to be asked in history taking. An LLM tool can be an adjunct to ‘cross-check’ if all salient points were captured.

LLMs could potentially be assistive in improving patient communication skills among students and junior doctors.AI systems could aid in generating facts that are comprehensible to non-medical personnel. This ability is particularly helpful for students in generating content to practice patient communication skills. Accuracy and suitability of such information should be objectively assessed, before recommending LLM tool use for this purpose.

The LLM technology is a tool that can augment the process of multi- dimensional education, encompassing competency-based approaches to education, in addition to discipline-based education. This multidimensional approach comprises knowledge along with various other skills including professionalism, communication, practice-based learning, and patient care. This approach demands more commitment from students and educators and requires more learning resources. With the emergence of more sophisticated AI technologies, harnessing of LLM capabilities could be explored as future learning resources to be developed.

Unbundling and rebundling the curriculum is a concept that emphasizes revising the existing curricula by combining various educational resources including textbooks, lectures and web-based resources (Morris et al., 2018). This is pertinent to the multi-dimensional approach discussed above. The advances in current LLM tools have the potential to become an integral component of the curriculum bundle to meet the demands of reformations in modern medical education. 

Potential negative implications of LLM tools have caused anxiety among educators. Firstly, the content generated may not be accurate at all times. LLMs generate responses from language patterns learnt from the training data and not from a deeper understanding of a subject. This is also compounded by the inability of some LLMs to link to external resources to gauge the validity of the output. Another limitation of the current LLM technology is ‘hallucination’ to create non-existent or wrong information in a convincing manner. (Lee et al., 2023) Consequences of such information could cause huge impact particularly in patient safety in medical education.  

LLMs have potential negative implications on the evaluation of students’ learning. In modern-day multidimensional education, assessments have moved a long way from traditional examinations to include projects, assignments, and research. Certain assignments are designed to foster the development of critical thinking and analytical skills. AI tools may direct students to take an easier path in completing these tasks, impeding the accomplishment of intended learning outcomes.

There is no consensus on how this technology should be adopted in higher education. At the start, certain educational institutes banned the use of LLMs, and software was developed to detect work done by AI. These approaches are not sustainable in the long run.

Users should have a clear understanding on potentials and imitations of current LLM technology, in order to use LLMs effectively.

LLM technology is improving rapidly, and efficacious compared to many other sources of education. However they are not yet at a standpoint to be recommended as the primary source in education, rather, they could be adjuncts to standard resources like lectures, textbooks, peer-reviewed literature, and online materials. Students should know when and when not to use it, and the content should be critically and cautiously looked into.

Educators have a crucial role in guiding the students on using AI effectively. Navigating students to experience the limitations of LLMs through practical scenarios is a potential strategy. An example would be to assign students to critically analyse a draft answer generated through an LLM platform. This will allow both the students and tutors identify the capabilities and limitations of LLMs.

In the context of evolving LLMs educators have to re look into the existing assessment modalities and implement changes to ensure the potential objectives of the assessment are met. The policies regarding LLM use for the particular task should be clearly communicated to the students on contextual basis.

Impacts of LLMs on educational development is yet another area warranting discussion. This encompasses exploring the role of LLMS in instructor, instructional and organizational development. We didn’t include it within the scope of this write up.

In summary, generative AI could be harnessed to potentiate students’ learning, in knowledge acquisition as well as application. Even though LLM tools may pose challenges, we foresee a larger potential for the betterment of medical education, ultimately leading to the overall goal of better patient care. 

Notes on Contributors

WANVL, CTY, RT, DS and KB were involved in planning of the article.

WANVL drafted the initial version of the mauscript.

WANVL, CTY, RT, DS and KB revised and edited the initial draft manuscript and approved the final version of the manuscript for submission.

Funding

The authors received no financial support for the authorship or publication of this article.

Declaration of Interest

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

References

Kelly, S. M. (2023, January 26). ChatGPT passes exams from law and business schools. CNN Business. https://edition.cnn.com/2023/01/26/tech/chatgpt-passes-exams/index.html

Kung, T. H., Cheatham, M., Medenilla, A., Sillos, C., De Leon, L., Elepaño, C., Madriaga, M., Aggabao, R., Diaz-Candido, G., Maningo, J., & Tseng, V. (2023). Performance of ChatGPT on USMLE: Potential for AI-assisted medical education using large language models. PLOS Digital Health, 2(2), Article e0000198. https://doi.org/10.1371/journal.pdig.0000198

Lee, P., Bubeck, S., & Petro, J. (2023). Benefits, Limits, and Risks of GPT-4 as an AI Chatbot for Medicine. The New England Journal of Medicine, 388(13), 1233–1239. https://doi.org/10.1056/NEJMsr2214184

Morris, N., Ivancheva, M., Swinnerton, B., Coop, T., & Czerniewicz, L. (2018, September 11-13). Critical perspectives on unbundling and rebundling higher education provision online [Research session]. [18-97]. ALT Annual Conference, Manchester, UK. https://www.youtube.com/watch?v=F2FS0n3Dr0k

Ramanathan, R., Shanmugam, J., Gopalakrishnan, S. M., Palanisamy, K. T., & Narayanan, S. (2022). Challenges in the Implementation of Competency-Based Medical Curriculum: Perspectives of Prospective Academicians. Cureus. https://doi.org/10.7759/cureus.32838

*Celestial T Yap
Department of Physiology
Yong Loo Lin School of Medicine
National University of Singapore
+6590560468
Email: phsyapc@nus.edu.sg

Submitted: 21 December 2023
Accepted: 3 July 2023
Published online: 3 October, TAPS 2023, 8(4), 46-49
https://doi.org/10.29060/TAPS.2023-8-4/PV2934

Dhivya Subramanian

School of Medicine, University of Dundee, United Kingdom

Portfolio has been used since the early 15^th century to showcase designs, and folders of work for architectural, artistic and financial purposes. Though the method of delivering a portfolio has shifted over the years from a “folder of loose papers” to “electronic portfolios” with the advent of technology; the crux of portfolios has remained the same. The purpose of portfolio to allow for a personalised approach for each individual to showcase their knowledge, professional values and skills has remained constant over the past hundreds of years. (Buckley et al., 2009) The usage of portfolio in medical education has been thought to give students more responsibilities for their own learning and development and aid in stimulating the reflective thought process (Driessen et al., 2003). Moreover, portfolio has been considered being a more holistic approach to assessing students in medicine, which allows a broader method in assessment rather than a ‘snap-shot’ examination (Van Tartwijk & Driessen, 2009).

Portfolio was first introduced in the University of Dundee in 1997 and the first portfolio assessment occurred in 1999. Portfolios are formatively assessed from 1^st to 4^th year and are a summative assessment in 5^th, the final year (Davis et al., 2009). As a final year Singaporean student from the University of Dundee, I was introduced to the new concept of portfolio during my medical course (MBChB) and its importance was emphasised from the very beginning in Year 1. Appendix 1 underlines the portfolio requirements for the respective years. These requirements are regularly updated in our portfolio section on Medblogs (medical school website for students and staff), allowing us to check deadlines and ensure we are up to date with tasks required.

The portfolio in the University of Dundee and all universities in the United Kingdom is based on the 3 Outcomes of Graduates 2018 set by the General Medical Council (Outcome 1–Professional values and behaviours, Outcome 2–Professional skills, Outcome 3–Professional knowledge) (Monrouxe et al., 2018). All portfolios are uploaded on to the system known as “NHS e-portfolios” which provides a platform for all students throughout the nation to upload their works.

Four years ago, as a 1st year medical student, I found it hard to understand the importance of portfolio. The medical school organised lectures to inform us about the purpose of portfolio and its significance to aid our professional development. However, it appeared more of an abstract concept. Since the school gave information on what we needed to submit and when, it seemed more of a checklist of things we needed to finish. It was difficult to appreciate the holistic picture of portfolio and its purpose in our development as a medical professional.

Growing up in Singapore, practicing reflections was not part of our culture. A more difficult task-oriented environment is what most of us are used to during our schooling and work life in Singapore. The concept of reflections was new and seemed redundant, however as years went by and when I entered the clinical years of medicine (year 4 and year 5), I began to understand why the emphasis on reflection was so strong.

The reflective essays we add in our portfolio can be chosen from a list provided to us but also can be done on topics we choose ourselves to reflect on. This gives us freedom to decide what we felt was impactful during our placements and does not constrain us to write about certain issues, thus avoiding the ‘checklist-like’ feeling that can often be felt during the initial stages of developing a portfolio. The University of Dundee encourages the use of either Gibb’s cycle, Rolfe et al, or John’s model as reflective writing models to aid the reflection process.

Often my peers including myself would debate that reflections are things we do regularly, such as thinking about how the day went before we sleep or reflecting on action such as recognising a patients’ emotions while speaking to them and reacting appropriately. However, I recognised the importance of writing down reflections as we can look back at it in the future and learn from the past.

During my paediatric placement in 4^th year, I had the opportunity to reflect on a case I found myself getting emotionally involved. A two-year old child was vigorously shaken by his parents which led to a hypoxic brain injury and consequently cerebral palsy. Seeing the patient every day on ward rounds was disheartening as I could witness the stark difference between the neglected, immobile child and another child playing happily in the next bed. Upon reflecting, I could appreciate that there will be circumstances in the future where I encounter similar situations, and the practice of reflecting and debriefing with colleagues can aid in alleviating the emotional weight we take back home. This served as a turning point in appreciating the value of reflections as a medical student.

Even though portfolio assessments are summative in final year, the process of developing the portfolio became more genuine nearing the end of the course. On reflection, I would think this is mainly due to the realisation that the reflective process required in building a portfolio helped me become a better medical professional; with not only arming myself with the right skills but also enabling the confidence to perform well once we set foot into the clinical world as a Foundation Doctor / House Officer.

It is important to emphasise that it is not only reflective questions that use the skill of reflection. Reflections for feedback given for case discussions and clerkings allow us to reflect on the process of writing the essays and how we could improve in the future. The reflection serves as a critical interrogation which creates meaning from an event and urges us to act. I realised that only if one identifies their limitations and develops an action plan, they can work towards a target in mind. Setting an action plan paves path to avidly look for opportunities in order to gain more practice in those areas. This made me realise that it is truly up to an individual’s initiative whether they want to gain something useful from building a portfolio.

If I had the opportunity to tell my year 1 self something, I would advise to regularly update her portfolio rather than leaving it to the very end and to approach it as something she does for herself rather than to impress a supervisor or faculty member. Even if one does not understand the purpose of portfolio at the initial stages, completing reflections and small pieces of work are valuable as the skill is slowly starting to develop. Ultimately “every expert was once a beginner”.

Looking back at my portfolio and seeing all my achievements collated in one area fills me with a sense of pride and fulfilment. After all, portfolio is something you develop throughout your life; from the first year you start working till the day you retire. So why not start early if you can!

Notes on Contributors

Dhivya Subramanian is a final year medical student at the University of Dundee, UK. The author based this personal view from past experiences in developing a portfolio during the period of undergratudate medical school.

Acknowledgement

Thanks to Dr. Shuh Shing Lee for her support and guidance.

Funding

No funding has been received for this article.

Declaration of Interest

No conflicts of interest, including financial, consultant, institutional, and other relationships that might lead to bias or a conflict of interest.

References

Buckley, S., Coleman, J., Davison, I., Khan, K. S., Zamora, J., Malick, S., Morley, D., Pollard, D., Ashcroft, T., Popovic, C., & Sayers, J. (2009). The educational effects of portfolios on undergraduate student learning: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 11. Medical Teacher, 31(4), 282–298. https://doi.org/10.1080/01421590902889897

Davis, M. H., Ponnamperuma, G. G., & Ker, J. S. (2009). Student perceptions of a portfolio assessment process. Medical Educa- tion, 43(1), 89–98. https://doi.org/10.1111/j.1365-2923.2008.03250.x

Driessen, E., Van Tartwijk, J., Vermunt, J., & van der Vleuten, C. (2003). Use of portfolios in early undergraduate medical training. Medical Teacher, 25(1), 18–23. https://doi.org/10.1080/0142159021000061378

Monrouxe, L. V., Bullock, A., Gormley, G., Kaufhold, K., Kelly, N., Roberts, C. C., Mattick, K., & Rees, C. E. (2018). New graduate doctors’ preparedness for practice: a multistakeholder, multicentre narrative study. BMJ Open, 8(8), 1–15. https://doi.org/10.1136/bmjopen-2018-023146

Van Tartwijk, J., & Driessen, E. W. (2009). Portfolios for assessment and learning: AMEE Guide no. 45. Medical Teacher, 31(9), 790–801. https://doi.org/10.1080/01421590903139201

*Dhivya Subramanian
University of Dundee, Nethergate,
Dundee DD1 4HN, United Kingdom
Email: sdhivya1509@gmail.com

Submitted: 14 December 2022
Accepted: 22 March 2023
Published online: 4 July, TAPS 2023, 8(3), 62-64
https://doi.org/10.29060/TAPS.2023-8-3/PV2926

Sachiko Kasamo, Satoshi Ozeki, Hiroyasu Inoue & Seiji Matsumoto

Institutional Research Office, Asahikawa Medical University, Japan

I. INTRODUCTION

There is growing interest in social responsibility around the world in order to accomplish a sustainable society. Indeed, modern universities cannot be ivory towers unrelated to society. It would not be an overstatement to say that without interaction and contribution to society, the university’s survival and development are unlikely.

It is frequently said that the university fulfils three different missions: education, research, and social contribution. J. A. Perkins, the eminent theoretician of higher education in the 1960s, proposed there are three aspects of knowledge that must be understood as they have their institutional reflections in the university’s three missions (Perkins, 2016). For knowledge itself to have significant power, there must be communication and interaction between the newly acquired knowledge, its transmission, and its application. The above concept began in the United States and has since been widely adopted as three major missions in many universities worldwide. Despite these three missions, however, depending on the university’s expertise and readiness, and the resources and support received from external organisations and individuals, the university may be more active on some missions and less active on others.

Some with a conventional conception of “social contribution” may wonder “why now?”, as the results of both “education and research” are ultimately returned to society. However, the major difference is that while the conventional efforts of the university were at the level of individual responses by faculty members and others, the current “social contribution” is positioned as the essential function of the university. Expectations for universities have changed significantly, and universities have changed in a variety of ways; universities are now required to use knowledge for society from various perspectives. The greater the need to contribute to society and the greater its role, the more we need to question the meaning of “social contribution” in relation to the traditional roles of “education and research” in the university.

II. GLOBAL CONCEPTS OF SOCIAL ACCOUNTABILITY IN MEDICAL SCHOOLS

The concept of social contribution is embedded in the social accountability of medical schools. The World Health Organization defined it as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve” (Boelen & Heck, 1995). Following this, the Global Consensus for Social Accountability of Medical Schools defined a socially accountable medical school as one that “responds to current and future health needs and challenges in society, re-orientates its education, research and service priorities accordingly, strengthens governance and partnerships with other stakeholders and use evaluation and accreditation to assess their performance and impact” (Global Consensus for Social Accountability of Medical Schools [GCSA], 2010). This document also emphasised the significance of enhancing medical schools’ ability to address the demands and difficulties of providing healthcare for citizens and society at large, in accordance with the fundamental principles of quality, equity, relevance, and effectiveness. In addition, the criteria for ASPIRE-to-Excellence Award for Social Accountability by Association for Medical Education in Europe provide a practical framework for medical schools to consider when examining their own social contribution. This award itself gives schools the opportunity to be acknowledged globally for their excellence in education, which also covers social accountability (Mori et al., 2022). These internationally accepted concepts should always be kept in mind when promoting social contribution activities in medical schools.

III. SOCIAL CONTRIBUTIONS IN JAPANESE MEDICAL SCHOOLS

Japan might be one of the unique countries to set clear objectives regarding the university’s social contribution in legislation. There are two revisions that have pushed the idea of social contribution forward as a fundamental function of the university (Hosono, 2014). First, the 2006 Revision of Basic Act on Education, Article 7 stated, “Universities, as the core of scholarly activities, are to contribute to the development of society by cultivating advanced knowledge and specialised skills, inquiring deeply into the truth to create new knowledge, and broadly offering the fruits of these endeavours to society.” Second, 2007 Revision of School Education Act, Article 83(2) stated, “Universities shall contribute to the development of society by conducting education and research to achieve their objectives and by providing the results widely to the society.” In light of these key statement revisions, the mission of the universities has changed along with the social trends, and more direct social contributions are being sought.

The importance of social contribution is also emphasised by Japanese medical schools. The recent study has analysed the Japan Accreditation Council for Medical Education accreditation documents of 45 medical schools against a global framework, and revealed that social contribution is identified to be one of the key components in the main category of “issues in society” for social accountability (Mori et al., 2022). As an essential aspect of social contribution, the need for an individual’s lifelong learning has increased by an accumulation of factors, such as disaster-related disruptions, pandemics, and the ageing population with longevity. Medical schools can certainly use their strengths as health experts to assist in health literacy and well-being for the members of communities. In addition, the government has long been prioritising, promoting, and advancing lifelong learning in Japan, in recognition of global challenges and social changes. Therefore, social contribution activities by medical schools can come into play to satisfy the need of individuals, society, and the country.

IV. SOCIAL CONTRIBUTION THROUGH COMMUNITY LECTURES: A CASE FROM A REGIONAL MEDICAL UNIVERSITY

Here, we share an example of ongoing direct social contribution activity at our university. The university positions social contribution as a significant role and mission in Educational Philosophy, and our “Community Lectures (haken kouza)” constitutes one of the essential elements in this role. This activity began in 2002 to meet the local community’s lifelong learning needs, and the university’s members have been giving lectures at the request of local public organisations. There are over 350 different topics offered to date. The lecture themes are not limited to medical and nursing topics, but also include educational and cultural topics. Between 2016 and 2019, we provided over 600 lectures to the local and regional communities. As the northernmost medical university in Japan, it is necessary to devise something unique to the region that makes the best use of the regional characteristics, and we firmly believe that there is a stage for the university to play an active role.

V. WHAT, THEN, IS THE SOCIAL CONTRIBUTION OF UNIVERSITIES

We acknowledge that the above Community Lecture is just one example, and in fact, social contribution can take many forms and shapes and be offered at various levels. The social contribution made by universities must not be merely the provision of free labour or lending facilities, but should fully utilise the characteristics of the university as the base for intellectual creative activities. In other words, the knowledge acquired and transmitted through the university’s education and research activities should be returned to the local community by the mechanism of social contribution with the aim of improving the lives and welfare of the local population. The ideal relationship between the university and the community should not be a one-way relationship but should be a reciprocal one; where the community benefits from the intellectual and human resources of the university through community cooperation, and the university makes effective use of the region as part of its education and research.

In addition, activities such as international collaboration, regional collaboration, industry-academia-government collaboration, and training programs are all solid initiatives aimed at giving back to society in a more direct way. The university faculty and staff have been independently engaged in these activities as experts in their respective fields. These include serving on committees of administrative agencies, supporting science education in schools, joint research with industries, and public lectures for non-students. They voluntarily carry out these social contribution activities (without even recognising them as such) alongside their busy daily clinical duties, teaching and research. However, these activities are often missed or not subject to systematic evaluation by the universities. In the future, these activities should be highlighted and evaluated as important activities that play a role in the functions of universities. We hope this article will stimulate interest in expanding social contribution in the university context. For future work, we plan to review other areas of social contribution activities conducted at the university.

Notes on Contributors

Sachiko Kasamo reviewed the literature, conceptualised and took the lead in writing and editing the manuscript.

Satoshi Ozeki contributed to the conception and revision of the manuscript critically.

Hiroyasu Inoue contributed to the conception and theoretical ideas of the manuscript.

Seiji Matsumoto supervised and gave critical feedback on the intellectual content of the manuscript.

All the authors have read and approved the final manuscript.

Acknowledgement

We sincerely thank Ms Misako Sato (Institutional Research Office’s administrative staff) and the Research Support Section of Asahikawa Medical University for their support.

Funding

There is no funding source required for this study.

Declaration of Interest

All authors have no conflicts of interest to disclose.

References

Boelen, C., & Heck, J. E. (1995). Defining and measuring the so­cial accountability of medical schools. Geneva: World Health Or­ganization.

Global Consensus for Social Accountability of Medical Schools (GCSA). (2010). Global census for social accountability of medi­cal schools. https://healthsocialaccountability.sites.olt.ubc.ca/files/2011/06/11-06-07-GCSA-English-pdf-style.pdf

Hosono, M. (2014). Kokuritsu daigaku niokeru syakaikoukenka­tsudouno genjyou to kadai. [Current Status and Issues of Social Contribution Activities at National Universities]. The Journal of Science Policy and Research Management, 29(1), 44-49. https://doi.org/10.20801/jsrpim.29.1_44

Mori, H., Izumiya, M., Hayashi, M., & Eto, M. (2022). Current perception of social accountability of medical schools in Japan: A qualitative content analysis. Medical Teacher, 1-8. https://doi.org/10.1080/0142159X.2022.2140033

Perkins, J. A. (2016). The university in transition. Princeton Uni­versity Press.

*Seiji Matsumoto
Institutional Research Office,
Asahikawa Medical University,
2-1-1-1, Midorigaoka-Higashi,
Asahikawa, Hokkaido,
078-8510, Japan
Email: matsums@asahikawa-med.ac.jp