Submitted: 17 August 2020
Accepted: 30 September 2020
Published online: 13 July, TAPS 2021, 6(3), 111-113
https://doi.org/10.29060/TAPS.2021-6-3/PV2375

Nicholas Beng Hui Ng¹, Terri Chiong¹, Perry Yew Weng Lau¹ & Marion M Aw^1,2

¹Khoo Teck Puat – National University Children’s Medical Institute, National University Health System, National University Hospital, Singapore; ²Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. INTRODUCTION

The Coronavirus Disease (COVID-19) pandemic caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus has led to significant disruptions globally with alarming mortality rates and increasing economic burden. For the medical community, aside from massive changes in workflow, healthcare worker fatigue and direct risk of infection, COVID-19 has also resulted in significant disruptions to medical training. During a pandemic, it is not surprising that manpower, financial resources and time are allocated fully to contain the disease. We believe however, that structured teaching activities amidst this crisis play an important, if not pivotal role, in keeping the medical community united and informed of the rapidly changing evidence surrounding this disease. Our department instituted measures to ensure that disruptions to post-graduate training were minimised amidst the clinical workflow changes. In this article, we share our experience of how teaching activities were sustained through implementing various strategies. We also discuss the benefits derived from ongoing teaching during this pandemic.

II. EXECUTION AND EXPERIENCE

When Singapore first announced the escalation of the Disease Outbreak Response System Condition (DORSCON) alert level from yellow to orange in response to increasing community spread of COVID-19, all healthcare institutions immediately put in place protocols and workflow to cope with the demands of COVID-19 (A Singapore Government Agency Website, 2020). Our department, a paediatric department in a university hospital, followed suit with plans for team segregation and clinical workflow protocols for children with respiratory illnesses. At the same time, all face-to-face teaching activities and meetings were suspended, in an attempt to minimise gatherings of clinicians.

The Residency Programme Director quickly formed a dedicated Education Task Force (ETF) to look into adapting the post-graduate teaching activities to take into account clinical service needs, as well as team segregation. Prior to the pandemic, our post-graduate teaching (in additional to clinical learning on the job) were largely based on face-to-face large group sessions, as well as small group clinical bedside teaching.  As the department adjusted to the new COVID-19 clinical workflow, the ETF effectively morphed the delivery of post-graduate education to cater to the education needs of residents and faculty.

Our teaching sessions have been transformed from in-person to on-line delivery via the Zoom video-conferencing platform. This has allowed residents (interns, medical officers, senior residents) from different clinical locations, who are not allowed to meet physically, to attend. An added benefit is that residents off-site may also choose to attend these teaching activities. In addition, faculty members who would previously not attend resident teaching have also been able to attend these sessions and collectively contribute to the teaching and learning process. We have been able to conduct almost all our continued medical education (CME) programmes via video-conferencing; journal clubs, mortality rounds, radiology rounds, topic reviews, history taking sessions, case-based discussions and importantly, COVID-19 clinical workflow updates.

The ETF outlined ground rules for the on-line teaching sessions at the outset: participants have to sign in with appropriate identification, unmute microphones only when speaking and respect the confidentiality of teaching materials without taking pictures or recordings unless explicit permission is obtained. In order to ensure the security of these video-conferencing sessions, each session is managed by a host, with controlled admission of participants.

A. Modified Clinical Teaching

During this pandemic, we have been able to continue clinical history-taking teaching sessions for residents with real patients via video-conferencing. In this format, one resident in the “hot-seat” takes the history from the patient remotely, while other participants observe the encounter via a live video stream from different locations. This “live” history-taking session is followed by a discussion between the resident and faculty on the patient’s clinical history as well as management. Other residents are also able to participate in the discussion. We have been extremely encouraged by the responses from patients and their families who have readily consented to these video-streaming teaching sessions. Our experience has reinforced the notion that patients are willing to participate in medical education as a means to give back to the medical community (Stacy & Spencer, 1999; Thomas et al., 1999). In a time of crisis like this, where the medical community has to quickly learn and rapidly adapt to new discoveries of COVID-19, the role of patient involvement in teaching and research cannot be better overstated.

B. Specific Mock Code Training

Aside from core teaching sessions for residents, the department quickly recognized the importance for on-the-go pandemic-preparedness training for the residents. Faculty from the critical care division has developed COVID-19 relevant mock code scenarios for residents using high fidelity simulation equipment. These sessions are conducted during designated time slots and adhere to the team segregation plans. The scenarios involve the use of powered air-purifying respirator (PAPR) equipment and personal protective equipment (PPE). Residents are given the opportunity to perform the initial clinical assessment, cardio-pulmonary resuscitation and intubation, as well as communicate with the rest of the clinical team whilst dealing with mock patient emergencies in negative-pressure isolation facilities. Many of the junior doctors as well as nurses quickly realized the added challenge of performing seemingly standard resuscitation in isolation facilities whilst in full PPE. Routine tasks such as communication between team members, preparation of drugs, use of resuscitation drug charts and even mobile phones while wearing PAPR and PPE can be extremely difficult. These simulation sessions highlighted to us that good planning, coordination and communication between healthcare workers are all the more crucial while resuscitating in a COVID-19 setting.

C. Increase Trainee Participation

An initial unanticipated benefit of this style of teaching and learning was increased trainee participation in these sessions. We noticed that a proportion of residents who would otherwise have remained silent in an open group teaching encounter were now more willing to ask and answer questions, either through their voice audio or using the chat function of the Zoom platform. What is most interesting is that when we compared our teaching attendance rates for residents at these video-conferencing CME compared to the usual face-to-face teaching, there was an increase from an average of 32% (pre-COVID-19) to 68% (during COVID-19) in daily attendance rates. This increase attendance was seen for both COVID-19 and non-COVID-19 related teaching sessions, suggesting that it was not only the COVID-19 updates that drew participation for these sessions. Contributing factors could include the ease of access afforded by learning from various (remote) locations, particularly for residents posted off-site who are unable to travel back. In addition, the Zoom video-conferencing tool is readily available on a variety of platforms, including laptops, tablets and mobile phones.

D. Limitations and Challenges

The main issue raised had been that of internet connectivity in certain areas around the hospital, but this has been rectified with specific locations allocated as “teaching hubs”.

Another shortcoming of the on-line teaching programme is that bedside teaching for clinical skills has not been possible, in the interest of staff and patient safety. The ETF has since explored other innovative approaches; using video clips of clinical signs, as well as preparing pre-taped clinical examination signs with patient and caregiver consent.

III. THE RECIPE TO SUCCESS

The feedback received from residents for this on-line delivered teaching has been extremely positive, with 42 of 46 residents rating it positively on a feedback survey. Many of our residents look forward to attending these sessions, not only as a means to learn, but also as an opportunity to connect with fellow colleagues.

We believe that our success in maintaining a relevant teaching programme during the COVID-19 pandemic is attributed also to the following factors:

• Strong teaching culture with a mission of ensuring that residents are appropriately trained.
• Faculty realising the importance of pandemic-preparedness training for residents.
• The ability to innovate and the flexibility to adjust the delivery of medical education to meet the needs of the current pandemic situation.
• The availability of reliable resources and use of latest educational technology such as the Zoom Video-Conferencing to allow delivery of web-based teaching.

IV. CONCLUSION

As our health workers continue to brave the frontline battling against COVID-19, we are frequently reminded of the importance that flexibility and adaptability is crucial during this pandemic. While we continue to deliver the best possible patient-centred care and ensure the safety of our healthcare workers amidst this COVID-19 pandemic, structured teaching in our department continues to be an important part of our daily routine. We experienced first-hand the benefits of web-based learning and would retain some of these sessions post-pandemic. The deliberate strategies taken by our department to ensure that teaching activities continue has allowed learning to persist in a structured and relevant way. Importantly, on-the-go training for pandemic-preparedness for residents is a highly valuable skill to teach during this time. We are very proud to be able to continue to learn and keep abreast the latest developments on COVID-19 as a department. As former United States First Lady, Abigail Adams so eloquently said, “Learning is not attained by chance, it must be sought for with ardour and attended to with diligence”.

Notes on Contributors

Ng Nicholas Beng Hui contributed in design, analysis and interpretation of data, drafting the article, and final approval of the version to be published. Chiong Terri contributed in analysis and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published. Lau Perry Yew Weng contributed in conception and design, and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published. Aw Marion M contributed in conception and design, and interpretation of data, revising it critically for important intellectual content, and final approval of the version to be published.

Acknowledgement

We thank Dr Dimple Rajgor for helping with in editing, formatting and in submission of the manuscript for publication.

Funding

No funding is required for this paper.

Declaration of Interest

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

References

A Singapore Government Agency Website. (2020). Additional measures introduced with DORSCON Orange Singapore. Retrieved March 10, 2020, from https://www.gov.sg/article/additional-measures-introduced-with-dorscon-orange

Stacy, R., & Spencer, J. (1999). Patients as teachers: A qualitative study of patients’ views on their role in a community‐based undergraduate project. Medical Education, 33(9), 688-694.

Thomas, E. J., Hafler, J. P., & Woo, B. (1999). The patient’s experience of being interviewed by first-year medical students. Medical Teacher, 21(3), 311-314. https://doi.org/10.1080/01421599979608

*Ng Nicholas Beng Hui
Khoo Teck Puat-National University
Children’s Medical Institute,
National University Health System,
1E Kent Ridge Road,
NUHS Tower Block Level 12,
Singapore 119228
Email: nicholas_bh_ng@nuhs.edu.sg

Submitted: 28 July 2020
Accepted: 23 December 2020
Published online: 13 July, TAPS 2021, 6(3), 104-107
https://doi.org/10.29060/TAPS.2021-6-3/PV2363

Tushar Hari¹, Dennis Hathey¹, Sonia Kumar², Ilona Blee², Rachel Browne³ & Simon Tso³

¹Buckingham Medical School, United Kingdom; ²South Warwickshire National Health Service Foundation Trust, United Kingdom; ³Jephson Dermatology Centre, South Warwickshire National Health Service Foundation Trust, United Kingdom

I. INTRODUCTION

We live in unprecedented times with the COVID-19 pandemic disrupting our normal way of life. First identified in December 2019, the novel SARS-CoV-2 strain has brought about vast devastation. According to the World Health Organisation (WHO), as of 21st November 2020, there are 56.9 million confirmed cases and 1.3 million deaths worldwide. The government approach to control the spread of COVID-19 in the United Kingdom (UK) is underpinned by social distancing measures; to limit the spread and prevent the inundation of National Health Service (NHS).

Social distancing impacts society on both an individual and population level. Across the country, virtual learning has become the new normal. It is our experience at Buckingham Medical School that students saw their clinical placements suspended. Educational resources were shared via online platforms and final year examinations done remotely to fast-track the transition to newly qualified doctors with an interim registration with the UK General Medical Council (GMC).

In this opinion piece, a diverse panel of two medical students, two doctors-in-training and two educators, including individuals with international student status, learning and sensory difficulties, chronic diseases, and dependents, discussed the impact on undergraduate medical education for individuals who may risk being left behind if efforts towards widening participation are not considered amidst this crisis and its aftermath. The focus group was held as an online asynchronous unstructured discussion through emails over a three-month period, moderated by a consultant, who regularly posted questions for the groups to discuss. This was supplemented by face-to-face discussion between the participants to summarise key outcomes and then circulated the conclusions to the panel before manuscript inclusion. Verbal consent was obtained from participants.

II. OVERVIEW: THE CHANGING LANDSCAPE OF UNDERGRADUATE MEDICAL TRAINING IN THE UK

What was once a curriculum encompassing face-to-face clinical teaching to deliver a degree in medicine, has now become reliant on the virtual learning environment (VLE).

In the UK, medical teaching methods vary between institutions. Under such unprecedented times, these long-established methods of education have required immediate reform, with VLE taking over and clinical teaching being significantly reduced or temporarily paused (Taha et al., 2020).

The use of VLE in UK medical schools has increased within the last decade. Many already utilise VLE for lecture recording, uploading learning materials, or online assessments. Challenges with virtual teaching existed before COVID-19, particularly the lack of time for educators to become familiar with and implement online learning. Some educators view virtual teaching negatively and thus engage poorly with these platforms (O’Doherty et al., 2018). These learning platforms may also be perceived as expensive. However, need is a big driver for change. With the COVID-19 pandemic forcing the need for socially distant learning, many institutions have become more receptive to this change and many students are benefitting from the flexibility of engaging with the material remotely.

Since the start of the pandemic, medical schools have begun to disseminate pre-recorded or live lectures using online platforms such as Microsoft Teams or Zoom. Simulations of the clinical setting are being recreated to accommodate for the loss of practical experience and provide medical students in the early stages an introduction to the clinical environment. Reduced opportunity for workplace-based clinical learning, suspension of rotational training and medical electives could also potentially impact on career choices due to a lack of exposure.

Student pastoral care is vital during this pandemic, with new anxieties and stresses arising daily. This can be continued on these virtual platforms, either as one-to-one sessions or in tutorial groups. However, members of our focus group expressed how they found video conferencing less personal, and difficulty with internet connections can make it hard to discuss personal problems.

III. INCLUSIVITY AND WIDENING PARTICIPATION CONSIDERATIONS

The GMC states that: “a diverse population is better served by a diverse workforce” (General Medical Council, 2018). Much effort has gone into widening access to medicine and focusing on inclusivity and diversity within medicine. This work must not be forgotten amidst this crisis.

A. Our International Community of Medical Students in the UK

An international UK medical student from our focus group explained that governments are advising their citizens abroad to return home. COVID-19 has impacted countries to varying degrees and many students have been recalled to help with national efforts such as volunteer work and contact tracing. With medical school teaching resuming via VLE in the UK, the challenge of now balancing voluntary commitments at home, family life and university work is made more difficult by differing time zones. Educators in the UK should bear in mind that these factors could impact on students’ level of engagement and learner satisfaction with online synchronous learning opportunities. Furthermore, access to certain learning resources such as the electronic British National Formulary and NICE (National Institute for Health & Care Excellence) guidelines is restricted outside the UK, causing difficulties with revision for some. Many have expressed concern regarding the future of their degrees; with questions around when respective governments will change travel advice so that they can return to the UK, and implications of the pandemic on their visas and degree duration. This uncertainty and stress are impacting some international students’ focus on their degrees. International students have also found positives to the new methods of teaching. Many students shared that online learning is more engaging compared to live classes and easier to access, ensuring standardised availability of resources for all, regardless of location. Also, many are content to be home with family support during a time of international crisis.

B. Students with Sensory Disability, Learning Differences and Chronic Diseases

In 2016/2017 the proportion of students with a declared disability was 9.3%, rising to 10.4% in 2017/2018 (General Medical Council, 2021). In the time of COVID-19, having a disability or chronic disease presents an additional barrier to effective workplace-based learning. Specific learning differences could impact on students’ ability to assist on ward round activities such as documentation. Documentation in medical notes at our institution is now performed away from patients’ bedside following completion of daily ward rounds due to infection control considerations. This presents student scribers with difficulties in working memory or other specific learning differences, the additional challenge of recalling large volumes of complex information after an event. In our real-life example, the clinician supported and debriefed the student after the ward round, and ensured the student had adequate time to document the plan in the patient notes, demonstrating a positive example of inclusivity.

Medical students with hearing impairment require lip-reading as a communication adjunct. Unfortunately, implementation of using face masks in the clinical setting limits this and there is a lack of availability of medical grade transparent face masks. Therefore, considerations on using appropriate debriefing and non-verbal communication skills such as hand gestures and written forms of expression can be vital in delivering a complete learning experience for students.

Many vulnerable students are concerned about their risks of contracting COVID-19 and thus their ability to complete their degree in the original timeframe. High-risk individuals have been advised to avoid clinical areas or even isolate at home. Students must fulfil time-based and performance-based criteria to be awarded a GMC-recognised medical degree, but the loss of time and clinical experience in a compact degree programme could put into question their ability to complete on time.

C. Students with Dependents

Students with dependents and those balancing part-time work with medicine to ease the financial burden of their degree could also require additional support. Universities and Colleges Admissions Service (UCAS) guidelines state, a student who holds responsibility for a child aged 17 or younger, should have access to additional support with studies (Universities and Colleges Admissions Service [UCAS], 2021). Students with dependents face many challenges during their degree due to personal obligations. The VLE offers students with dependents an opportunity to maintain their learning at a time when access to schools and care facilities are restricted during the lockdown, but this also presents the challenge of learning and completing coursework while simultaneously caring for their dependents. For some, a distinction between the place of study and the home environment was key to maintaining an effective work-life balance. The availability of care facilities, financial health of students and access to university hardship grants and support systems, would be key to maintaining this group of students’ participation in studying medicine.

IV. CONCLUSION

From our experience, the COVID-19 pandemic has changed the delivery of undergraduate medical education at the current time – whether these changes persist remains to be seen. Educators should be considerate about student support in this new way of working, to benefit all students. This applies especially to those with undeclared or undiagnosed learning difficulties, disability, chronic disease, and those with dependents, to encourage their full participation in all available workplace and online-based learning activities and integrate them into the clinical team. It is also important to implement the perceived advantages of VLE in future medical curricula. Further literature is required to see if these changes have truly made a positive impact on learning. Such inclusion is crucial to not deter students from continuing medicine. Neglecting the demands for these groups can hinder our previous efforts at widening participation within the NHS.

Notes on Contributors

Tushar Hari was involved mainly with creating the first draft of the paper and leading the focus group. He contributed some of his experiences as an international student. He participated in revising the paper prior to submission.

Dennis Hathey was involved with initially drafting the paper and helped organise the focus group. He was involved with designing the focus group questions and gathering various perspectives. He took part in final approval of the published version as did all the other authors.

Dr Sonia Kumar contributed to shaping the paper in the later stages and added input on all aspects of the paper. She helped with data collection and critical appraisal of the final draft of the submitted paper.

Dr Ilona Blee added input into the needs of disabled students and overall shaped the paper to its final draft. She played an important role in approving the final copy and contributed to data analysis and interpretation.

Dr Rachel Browne contributed to final changes made to the draft and made final approval of the paper along with the other authors.

Dr Simon Tso contributed to the final approval of the paper and helped supervise the conception and progression of the paper and focus group.

In summary, all authors fulfill the four criteria stated for authorship.

Acknowledgement

We would like to express our gratitude to our focus group participants for their contributions.

Funding

No funds were required for this paper.

Declaration of Interest

We have no conflicts of interest to disclose.

References

General Medical Council. (2018). Medical school reports. https://www.gmc-uk.org/education/reports-and-reviews/medical-school-reports.

General Medical Council. (2021). Who is a disabled person. https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/welcomed-and-valued/health-and-disability-in-medicine/who-is-a-disabled-person.

O’Doherty, D., Dromey, M., Lougheed, J., Hannigan, A., Last, J., & McGrath, D. (2018). Barriers and solutions to online learning in medical education – An integrative review. BMC Medical Education, 18(1), 130. https://doi.org/10.1186/s12909-018-1240-0

Taha, M., Abdalla, M., Wadi, M., & Khalafalla, H. (2020). Curriculum delivery in Medical Education during an emergency: A guide based on the responses to the COVID-19 pandemic. MedEdPublish, 9(1), 69. https://doi.org/10.15694/mep.2020.000069.1

Universities and Colleges Admissions Service. (2021). Students with parenting responsibilities. https://www.ucas.com/undergraduate/applying-university/individual-needs/students-parenting-responsibilities

*Tushar Hari
Buckingham Medical School
Yeomanry House, Hunter Street,
University of Buckingham
Buckinghamshire, UK, MK181EG
Email: 1606656@buckingham.ac.uk

Submitted: 20 July 2020
Accepted: 30 September 2020
Published online: 13 July, TAPS 2021, 6(3), 108-110
https://doi.org/10.29060/TAPS.2021-6-3/PV2369

Kimberly Hires¹ & Colleen Davis²

¹Lewis College of Nursing and Health Professions, Georgia State University, United States of America; ²Leadership Development, Vuselela Davis, South Africa

I. INTRODUCTION

Historically, health professional education has focused on the development of clinical expertise over leadership skills that enable practitioners to lead dynamic teams who can adapt and pivot rapidly in a crisis. Clinical acumen and the ability to lead effectively are not mutually exclusive within healthcare systems. Leadership development is vital for health professionals as it allows them to lead patients and health systems, adapt to rapidly changing healthcare environments, and elicit optimal performance from their teams—all of which lead to improved health outcomes. The COVID-19 crisis highlights an opportunity to innovate health professional education to create practitioners who can treat and lead with excellence.

In December 2019, the Wuhan Municipal Health Commission reported four cases of pneumonia of an unknown origin. The cluster of cases were the first sign of COVID-19. COVID-19 is caused by a novel coronavirus that can spread from person to person. Within six months, the virus spread to 231 countries and infected over 13 million people worldwide. In attempts to slow the spread of the virus, countries issued emergency shutdowns, schools were closed, global travel was prohibited, and every industry was affected. One industry most affected by COVID-19 is the healthcare industry. Healthcare infrastructures are facing unprecedented challenges to meet the demands for care related to COVID-19. Providers are battling burnout, insufficient supply of personal protective equipment, depression, anxiety, job dissatisfaction and in some cases increased rates of suicide (Greenberg et al., 2020). To identify the contributing factors to challenges faced by health professionals during COVID-19, leaders must go to the root: health professional education.

Current health professional education competencies prioritize the development of hard skills that focus on clinical performance or evidence-based practice over the development of soft skills that facilitate building healthy interpersonal relationships, self-awareness, communication, leadership skills and effective coping (Albarqouni et al., 2018). Health professions encompass art and science. Current health professional education rewards the science of healthcare but starves the art of leadership. The COVID-19 pandemic, has created a collective trauma within the global community for which current leaders are not equipped to respond (Greenberg et al., 2020). The evidence for COVID-19 is constantly changing and leaders do not have the confidence and care algorithms to which they have grown accustomed. Due to COVID-19, health care workers worldwide have experienced an increase in depression, anxiety, and other forms of psychological distress. Health professionals already experience higher levels of burnout and job dissatisfaction than other professions; COVID-19 has amplified existing challenges for healthcare leaders who were struggling with employee recruitment and retention prior to the global pandemic.

As COVID-19 becomes a critical component of the world’s new normal, this is the optimal time for health professional education to innovate and prepare graduates who can lead in the midst of the new normal. This paper draws on experience of the two authors and their work with students enrolled in health professional programmes at the initial level and the specialist level, as well as the post-academic level in the United States and South Africa. This paper aims to introduce a new model of leadership development informed by over three decades of observations from combined experiences in health professional education, hospital learning and development, and leadership coaching.

II. DISCUSSION

Top down, traditional styles of leadership with an emphasis on self-sacrifice do not have a future in 21st century healthcare leadership. Leaders who are highly aware, connected, and genuinely compassionate experience success in productivity, high performing teams, cost effectiveness, strategy, innovation and employee retention. Just as health professional education relies on evidence-based practice, the Human-based leader (HBL) Model was developed to explain how effective leadership skills are developed. The HBL model utilizes an ecological framework. Ecological systems theory was developed by Urie Bronfenbrenner and posits that development is guided by interactions between an individual and the surrounding environment; this interaction populates a system (Bronfenbrenner, 1979). Bronfenbrenner’s original system is comprised of four systems represented as four concentric circles: the individual/microsystem (the core), mesosystem (second sphere), exosystem (third sphere), and macrosystem (fourth sphere) (Bronfenbrenner, 1995).

The HBL is comprised of three concentric circles. At the core is phase I. The goal of phase I is the development of self-awareness. The microsystem (the individual/leader) is housed within this sphere. The next sphere is phase II which houses the mesosystem (relationships with others such as family, friends, team members, peers) and the exosphere (additional factors related to the organization including patients and the community). In phase II leaders develop an awareness of others. The third sphere, phase III, houses the macrosystem (factors related to the profession, population, values, and cultural customs). Development of this phase allows the health professional leader to contribute to the building of a global community. The HBL makes the following assumptions: (1) Leadership development is a dynamic process that is influenced by exchanges between the individual (the leader) and the environment. (2) Leadership development is a continuous process. (3) Leadership success is not limited to job related competencies. Success includes healthy organizational culture, employee job satisfaction, recruitment, retention, customer/client satisfaction, and work-life balance as well as profit and loss.

Historically, health professional education focuses on team development and neglects teaching students how to understand their own experiences and worldview. Engaging in reflective practices are vital for professional identity development, however, current practices limit the reflection to clinical experiences (Wald, 2015). This approach ignores the very rich and varying life experiences students bring with them into a health professional programme. These life experiences follow students well into practice. Healthcare leaders with decades of experience are often surprised to find how influential their worldview is on patient care and working within teams. In this phase, it is vital for the individual to be able to answer, “Who am I?” beyond the professional identity. As individuals reflect on who they are, they can identify triggers, motivators and fears. Seeing the Self and helping a leader understand the Why behind behaviour is fundamental to healing and growth for the leader and the organization. Leaders who are self-aware in a crisis, such as a pandemic, can move dynamically as the environmental norms shift.

Current practices in health professional education emphasizes teamwork, however, by ignoring phase I, health professional educators make a fallible assumption that self-awareness is not vital to working effectively in teams. If individuals are unable to see the humanness in themselves (self-awareness) to value their own stories, challenges, and uniqueness, then they will fail to see it in others (peers, staff). In this phase, leaders gain a clear understanding of how to connect with and motivate each member of the team for optimal performance and retention. Failure to successfully achieve this phase results in poor performance, increased risk for medical errors, and high turnover.

Once leaders have an awareness of self and an appreciation for others, then they can graduate to the macrosystem or global sphere. The COVID-19 pandemic has illustrated the power of globalization. Within six months, healthcare systems experienced a global rate of infection that needed a swift, fluid, innovative and agile response. It is imperative that health professional education helps students and future leaders develop a global paradigm that sees beyond local hospitals and communities. A healthy worldview facilitates an easier transition into a global macrosystem.

The HBL can be adapted and implemented at various levels of health professional education and practice. It can be incorporated as learning modules in existing courses at the initial level and as a formal coaching programme at the specialist and post-academic levels. At the initial level of health professional education, the HBL was implemented with students in their final semester of a health professional (baccalaureate) programme at a research institution in the United States. The model was integrated into a leadership and management course as learning modules, case-studies, and self-development activities to equip students with skills needed to successfully progress through phases I, II, and III. At the specialist level, health professional students in the United States benefited from a formal coaching programme comprised of individual and group coaching sessions delivered over 12 weeks. At the post-academic level, the HBL model was implemented with practitioners in the United States and South Africa. At the post-academic level, practitioners benefit from a formal, customised coaching programme comprised of individual coaching sessions or a combination of individual and group coaching sessions delivered over 12 to 16 weeks. The greatest challenge with implementing the HBL at the specialist and post-academic levels is facilitating the unlearning of maladaptive leadership behaviours that lead to unhealthy organizational culture.

III. CONCLUSION

As demands for quality health care increase, health professional education is charged with meeting the supply. COVID-19 has provided a unique disruption for global health professional education to pivot from a rigid, process-driven and task-oriented model towards a model of a self-aware, empathetic leader. The Asia Pacific health care market was significantly impacted by COVID-19. Building this model into health professional education curriculums now will result in increased resilience and retention among providers. The HBL model can be adapted to regional needs to provide guidance for health professional educators to help students embrace their unique worldview and experience, teach lifelong reflective processes, be effective members of teams, and significantly contribute to improving population health.

Notes on Contributors

Assistant Professor Kimberly Hires reviewed the literature, designed the manuscript, developed the conceptual framework, and wrote the manuscript. Colleen Davis developed the conceptual framework, developed the manuscript, gave critical feedback to the writing of the manuscript. All the authors have read and approved the final manuscript.

Acknowledgements

The authors thank all students, faculty, colleagues, and clients who have informed our model.

Funding

No funding was used for the development of this personal view.

Declaration of Interest

The authors declare no conflict of interest concerning any aspect of this research.

References

Albarqouni, L., Hoffmann, T., Straus, S., Olsen, N. R., Young, T., Dragan, I., Shaneyfelt, T., Haynes, R., Guyatt, G., & Glasziou, P. (2018). Core competencies in evidence-based practice for health professionals: Consensus statement based on a systematic review and Delphi Survey. Journal of the American Medical Association Network Open, 1(2), e180281. https://doi.org/10.1001/jamanetworkopen.2018.0281

Bronfenbrenner, U. (1979).  The ecology of human development: Experiments by nature and design.  Harvard university press.

Bronfenbrenner, U. (1995). Developmental ecology through space and time: A future perspective. In P. Moen, G. H. Elder, Jr., & K. Lüscher (Eds.), Examining lives in context: Perspectives on the ecology of human development. (pp. 619–647). American Psychological Association. https://doi.org/10.1037/10176-018

Greenberg, N., Docherty, M., Gnanapragasam, S., & Wesseley, S. (2020). Managing mental health challenges faced by healthcare workers during COVID-19 pandemic. British Medical Journal, 368, m1211. https://doi.org/10.1136/bmj.m1211

Wald, H. S. (2015). Professional identity (trans)formation in medical education: Reflection, relationship, resilience. Academic Medicine, 90(6), 701-706. https://doi.org/10.1097/ACM.0000000000000731

*Kimberly A. Hires
Georgia State University
Atlanta, GA 30302,
United States
Email: khires@gsu.edu

Submitted: 14 August 2020
Accepted: 14 October 2020
Published online: 13 July, TAPS 2021, 6(3), 114-117
https://doi.org/10.29060/TAPS.2021-6-3/PV2376

Meredith T. Yeung¹, Melissa Y. Chan¹, Clement C. Yan^1,2 & Katherin S. Huang¹

¹Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore; ²Department of Physiotherapy, Sengkang General Hospital, Singapore

I. INTRODUCTION

Coronavirus Disease 2019 (COVID-19), which requires no introduction, is transmitted through droplet transmission and is highly contagious (del Rio & Malani, 2020; Guan et al., 2020; Sohrabi et al., 2020). After it was declared a pandemic on 11 March 2020, the Singapore government implemented a “circuit breaker” period, or partial lockdown, on 7 April 2020 (Ministry of Health, 2020). In spite of numerous initiatives for faculty to embrace technology-enhanced learning over the past years, it was a steep take-off for most programmes at institutes of higher learning. This short personal view intends to share our experience from the sole entry-level physiotherapy programme in Singapore.

II. ONLINE LESSONS

During the preliminary stages of the pandemic, faculty proactively switched all face-to-face lectures and tutorials that involved 50 or more students to online lessons. As the academic timetable had already been established, there was little to no disruption to lesson scheduling. Synchronous methods of e-learning occurred via video-conferencing software, such as Zoom and Microsoft Teams, and was used for lectures and tutorials. The virtual classroom allowed live interaction, and was especially useful for small group case study discussions when students were allocated into breakout rooms. Asynchronous methods of e-learning took the form of pre-recorded lectures, predominantly via Microsoft PowerPoint or iSpring, or recordings of live lectures. This promoted ubiquitous learning where the learner could learn at a time and place of their convenience, and which garnered positive feedback of over 60% from an unofficial survey of students. One student commented that “the online lectures were very useful, especially those that are pre-recorded so [that we] won’t miss out on what the professor is saying”. 

While the move to online teaching was essential, it certainly had its challenges. Many of the faculty were not proficient with the advanced features of Zoom, resulting in initial hiccups in organising multiple lessons for over a hundred students. For example, being unfamiliar with the software, lack of stable Wi-Fi off-campus, and insufficient software accounts were some teething problems. Training workshops for the use of Zoom were initially planned prior to the pandemic, however these could not be realised due to sudden time constraints. Training and troubleshooting manuals were thus made available for all educators and students via an online portal, in addition to a phone helpdesk for further assistance. Furthermore, the other challenge we faced was the short amount of time available to produce and upload enough e-learning material, such as filming of teaching videos, organising self-directed packages, and modifying lecture material to suit live online or pre-recorded delivery. Students also faced challenges due to the multiple modules they were enrolled in during the academic term, having to keep track of up to five randomly-generated meeting identification numbers (ID) each day. The use of one meeting ID per module, set at a regular occurrence, was implemented to alleviate this burden. 

One concern we had was over “Zoom fatigue” and general lack of engagement from students. One strategy we implemented was to insert stretching exercises and a rest period after each hour of lesson. Quiz apps, such as Kahoot and Socrative, was also used to poll content-specific questions, to promote student engagement and active participation. These strategies helped to sustain attention span and was deemed successful as reflected by near-100% participant responses and structured module feedback. One student commented that she was “quite happy that we can still continue lessons, although it is modified…and not have to worry about the uncertainty of lessons being cancelled”. 

III. BLENDED FORMAT FOR PRACTICAL LESSONS

Physiotherapy students are highly dependent on skills-based learning and hands-on practice, which equips them with competencies to treat real patients in the clinical setting. Conducting practical lessons was met with additional challenges due to the strict rules on safe distancing, restrictions on human movement, and limits on class size and frequency. We approached this using video-augmented practicum. A pre-recorded demonstration of physiotherapy skills was disseminated to students via the learning management system (LMS) before each hands-on lesson. This strategy was useful for teaching of skills which require physical space and simulation, such as performing auscultation, manual handling, patient positioning and transfers, airway suctioning, or walking tests. To illustrate, in the teaching of cardiopulmonary exercise testing (CPET), we divided the content into several components: an introductory video and stepwise guide on how to conduct the exercise test; a self-directed learning package on CPET results interpretation with self-evaluation; and a hands-on practical session of performing the full CPET with peers in the human performance laboratory on university campus. Faculty then utilised the face-to-face practical sessions to provide critical feedback and correct students’ techniques. Students were further able to consult with faculty and receive real-time feedback on their performance of skills via video-conferencing, if requested. 

IV. CONDUCTING ASSESSMENT DURING A PANDEMIC

Following the declaration of the pandemic, our programme converted all physical paper examinations to online examinations. Commercially available remote proctoring systems, such as Respondus® and Proctortrack by Verificient, allowed us to mitigate cheating in the virtual environment. The three-point identity check in these systems ensures that authentication is vigorous, while the manual or artificial intelligence proctoring technology enables remote invigilation. ‘Browser lock’ disables platform-sharing functions such as screen-sharing or remote desktop control that would otherwise allow a proxy to take the examination. 

V. ONLINE VIVA VOCE

To assess the “thinking” portion of patient management, we conducted online viva examinations in lieu of physical examinations. To prepare for the large volume of online assessments, we underwent several trials of Zoom, tinkering with features such as the waiting room and breakout rooms. These trials enabled us to familiarise ourselves with the logistic flow, as well as troubleshoot issues such as interruptions during entrance and exit, transfer of host rights, and audio-visual glitches. Administrative coordinators were designated to manually allocate students into the breakout rooms, which was preferred over pre-allocation in order to reduce errors. In anticipation of potential lapses, we used a separate chat messaging software for assessors and coordinators to flag and resolve technical issues. A spreadsheet was used to schedule detailed information about switchover times and room allocation for each candidate, ensuring smooth transition from main room to breakout rooms, as well as to resolve any scheduling conflict. Advance dissemination of the examination schedule and login details was crucial in minimising technical issues. Marking rubrics with clear descriptors were developed, with time set aside for pre- and post-viva calibration amongst assessors. Students had access to the marking rubrics, and a mock run was held to familiarise students with the logistic flow of the assessment. With these preparations in place, we were able to conduct online viva examinations for over a hundred students successfully and efficiently. 

VI. VIDEO SUBMISSION FOR SKILLS ASSESSMENT

To assess the “doing” portion of patient management, we utilised video-based assessment. The evidence for video-based assessment in healthcare education is at its infancy, with most evidence evolving around the idea of video-based peer feedback, assessment for communication skills, or the assessment of surgical skills. We tested this method in a final-year elective module that required learners to demonstrate manually-assisted cough—a skill that would traditionally be performed in front of an assessor and marked against a checklist. Casually dubbed the ‘open-book practical assessment’, faculty listed detailed requirements of the assessment, which gave students time to practise skills before recording and submission. The use of student-generated video assessment (mean marks 77.84 ± 4.59, class size of 30) to replace traditional skills assessment (mean marks 80 ± 3.88, class size of 25) was considered a success as there was no significant difference in the pass-fail ratio between the affected cohort and prior cohorts. In addition, we observed some unintentional benefits, such as the demonstration of digital capability and communication skills by the students, while aligned with the learning and assessment objectives – a finding consistent with the available literature (Walters et al., 2015).

The assessment of skills may also be performed real-time through video-conferencing. However, the logistics and time required to assess such a large number of students within a relatively short timeframe made it a task too immense for us to undertake. Nonetheless, with adequate manpower and resources, it could undoubtedly be feasible, perhaps even superior, as a form of video assessment.

VII. CONCLUSION

The unprecedented COVID-19 pandemic has forced us to refashion pedagogical approaches to our curriculum and to embrace positive changes for the future of physiotherapy education. Utilising aforementioned strategies, we were able to deliver our teaching effectively and almost entirely virtually, despite initial hiccups. Pragmatically, it would be ideal to formally evaluate the impact of a virtual curriculum on established learning outcomes, as well as the general acceptability of such a programme for both students and faculty. In the event of future similar state of emergencies, it may even be prudent to develop a blueprint of and stepwise approach to pedagogy escalating along the spectrum of face-to-face methods versus virtual technology. We hope that this short personal view will provide other educators with some solutions to coping with the challenges of teaching surrounding this exigent time. 

Notes on Contributors

Meredith T. Yeung is an Associate Professor at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore. She contributed to the conception and revision of the manuscript critically for important intellectual content.

Melissa Y. Chan is an Associate Faculty at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore. She contributed to the conception and revision of the manuscript critically for important intellectual content.

Clement C. Yan is an Associate Professor at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore and Senior Principal Physiotherapist at the Department of Physiotherapy, Sengkang General Hospital, Singapore. He contributed to the conception and revision of the manuscript critically for important intellectual content.

Katherin S. Huang is an Associate Faculty at the Health and Social Sciences Cluster, Singapore Institute of Technology, Singapore. She contributed to the conception and revision of the manuscript critically for important intellectual content.

Acknowledgements

The authors wish to thank all students and staff members from the Singapore Institute of Technology and the physiotherapy programme for all the support during this challenging time of COVID-19. All comments and module feedback referred to in this article were willingly and voluntarily provided by students.

Funding

This personal view did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Interest

The authors declare no form of possible conflicts of interest, including financial, consultant, institutional and other relationships that might lead to bias or a conflict of interest.

References

del Rio, C., & Malani, P. N. (2020). 2019 Novel coronavirus – Important information for clinicians. Journal of the American Medical Association, 323(11), 1039-1040. https://doi.org/10.1001/jama.2020.1490

Guan, W., Ni, Z., Hu, Y., Liang, W., Ou, C., He, J., Liu, L., Shan, H., Lei, C., Hui, D. S. C., Du, B., Li, L., Zeng, G., Yuen, K.-Y., Chen, R., Tang, C., Wang, T., Chen, P., Xiang, J., … Zhong, N. (2020). Clinical characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine, 382(18), 1708–1720. https://doi.org/10.1056/NEJMoa2002032

Ministry of Health (2020, April 7). Speech by Mr Gan Kim Yong, Minister for Health, at the second reading of COVID-19 (temporary measures) Bill, 7 April 2020 [Press release]. https://www.moh.gov.sg/news-highlights/details/speech-by-mr-gan-kim-yong-minister-for-health-at-the-second-reading-of-covid-19-(temporary-measures)-bill-7-april-2020

Sohrabi, C., Alsafi, Z., O’Neill, N., Khan, M., Kerwan, A., Al-Jabir, A., Iosifidis, C., & Agha, R. (2020). World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery, 76, 71–76. https://doi.org/10.1016/j.ijsu.2020.02.034

Walters, S. R., Hallas, J., Phelps, S., & Ikeda, E. (2015). Enhancing the ability of students to engage with theoretical concepts through the creation of learner-generated video assessment. Sport Management Education Journal, 9(2), 102-112. https://doi.org/10.1123/smej.2014-0041

*Meredith T. Yeung
Singapore Institute of Technology,
10 Dover Drive,
Singapore 138683
Tel: +65 65928671
Email: Meredith.Yeung@SingaporeTech.edu.sg

Submitted: 30 September 2020
Accepted: 18 November 2020
Published online: 4 May, TAPS 2021, 6(2), 88-90
https://doi.org/10.29060/TAPS.2021-6-2/PV2407

Teng Chun Koh¹, Eugene Zhi Jie Lee¹, Charlene Jie Lin Yak¹, Jack Botao Sun¹, Joshua Ren Wei Tay¹, Ann Chong Hui Fong² & Clara Yuen Pun Mok³

¹Faculty of Dentistry, National University of Singapore, Singapore; ²Office of Undergraduate Education and Student Affairs, Faculty of Dentistry, National University of Singapore, Singapore; ³Discipline of Endodontics, Operative Dentistry and Prosthodontics, Faculty of Dentistry, National University of Singapore, Singapore

I. INTRODUCTION

Freshmen orientation programmes are important milestones of university life. In Dentistry, orientation helps build camaraderie and friendship among the small undergraduate student enrolment. Before the COVID-19 pandemic, freshmen orientation featured overnight camps, mass games and group activities which involved face-to-face interactions. With the pandemic, precautionary measures were put in place to curb the spread of the virus. A key measure was the radical move away from face-to-face activities. This had a profound impact on the conduct of the orientation programme in Dentistry. The authors share their experiences as student organisers of a first-ever online freshmen orientation programme (involving 72 freshmen and 60 seniors), and highlight key lessons gleaned from the experience.

II. E-ORIENTATION – CHALLENGING THE STATUS QUO

Planning and implementing an e-Orientation programme is vastly different from that of a conventional face-to-face one. While the latter leverages physical space, infrastructure, resources, and interactions to create a conducive environment to achieve the goals of Orientation, e-Orientation operates in the online space and relies heavily on technology. However, the ongoing COVID-19 pandemic necessitated a turn towards online platforms and tools for the execution of university orientation programmes worldwide (Ullman, 2020), and it was no different for students in the Faculty of Dentistry. As the organisers and planners of the programme, the lack of prior experience with such an online approach proved daunting for us and the challenges we faced included:

A. Managing Unfamiliar Online Tools

While technology was widely available to support the e-Orientation, familiarity with it was lacking. It was therefore necessary to overcome a steep learning curve and get acquainted with the use of new tools such as Zoom, the video-conferencing tool. 

B. Security, Privacy and Safety Concerns

A key concern with the e-Orientation revolved around security and privacy of the freshmen and seniors facilitating the online activities. Zoom was the platform of choice for our e-Orientation, due to its numerous security features, such as the usage of end-to-end encryption to secure meetings and the utilisation of meeting passcodes to ensure that only designated participants could access and enter meetings for e-Orientation (Zoom Communications Inc., n.d.).  Additionally, with many of the activities taking place remotely online, the physical safety of the participants was also a concern if any of them injured themselves during the activities. 

C. Sustaining Engagement of Freshmen

The long hours spent in front of the camera, coupled with the difficulty in engaging their peers over a virtual setting, resulted in participants quickly losing interest within a short time. The remote nature of the engagement also made it more difficult for the participants to deepen their interactions. The participants’ focus could be easily lost with them disengaging from the activities going on online. There was a need for the seniors to constantly exude high levels of energy and enthusiasm needed to keep the freshmen engaged. The lack of reciprocation from the freshmen did little to encourage the seniors.

D. Grappling with Technological Difficulties

An online orientation opened the possibility of technological difficulties presenting a stumbling block to the smooth flow of the entire programme. While the impromptu nature of these occurrences meant these problems could not be entirely headed off beforehand, proper planning for contingencies allowed us to deal with these issues swiftly and effectively when they arose.

III. RISING ABOVE THE CHALLENGES

The e-Orientation was organised primarily using Zoom with each Orientation group comprising 10 freshmen and 2 Orientation Group Leaders (OGLs). This helped to optimise the group size and maximise the online interactions. Over a two-week period, the activities were rolled out for two to three hours on alternate days. The longer duration and shorter engagement each day was deliberate to avoid online fatigue and provide ample opportunity to informally catch up online in smaller groups after the official programme ended each day. The following strategies contributed to the success of organising the e-Orientation.

A. Drawing from the Familiar and Conventional

Traditional games were creatively adapted for adoption online. An example was Human Cluedo where the freshmen messaged their group mates an assigned word to initiate conversations on their own. In the classic game of Cluedo, players attempt to deduce words that are hidden in an envelope, with the player who guesses right winning. In our version of Human Cluedo, every freshman was assigned a word, and had to complete a “murder” by making 2 other freshmen, their “victims”, say this word in their day-to-day conversations over text. If they did so successfully without arousing suspicion, they got a point for completing the “murder”! The “victims” on the other hand had to be wary and deduce the word that the murderer was trying to get them to say – the component of the game that was inspired by the original game. Inspiration was also sought from online games which the participants would be familiar with.

B. Experimenting with Newer Methods of Information Dissemination

While instructions could be given out efficiently through briefings in a face-to-face setting, this was not possible online. To reach out to the participants more effectively and expediently, an Instagram page was used to disseminate information quickly among the participants.

 C. Empowering and equipping Orientation Group Leaders

An Orientation Group Leader (OGL) handbook was developed to guide the student leaders in running the programme independently. It accorded them the flexibility to make adaptations to some of the activities if it was necessary. Zoom meetings were organised to familiarise the OGLs with the use of Zoom and dry runs proved quintessential in foreseeing and eradicating potential technical difficulties. 

IV. GOING VIRTUAL – A REALITY CHECK

Looking back on the e-Orientation, its success was the result of several values. First, the need to be open to new ideas and not discount any suggestions. The e-Orientation experience required new ideas to be tested to make sure these would still achieve the objectives of the Freshmen Orientation programme. Second, the need to see change as fresh opportunities. This also meant that any unexpected twists and turns to the original plans had to be embraced positively and recognised as opportunities to do something differently but with the potential to be better. Thirdly, perseverance proved an important ingredient in the recipe for success. With a major change to the original plans and being thrust into new unknowns, an easy way out would have been to cancel the orientation programme. This would have been an easier option, but not necessarily the correct one. The seniors persisted and rallied together to overcome the difficulties and eventually they succeeded in their foray into an online orientation programme. These values will go a long way in our training to become oral healthcare professionals of the future.

 V. CONCLUSION

There was a palpable sense of apprehension and fear in the beginning. There were many unknowns – would the camp proceed smoothly? Would the juniors enjoy themselves? Would it be overly awkward? Many thought that an online orientation programme would not be as fun and would not achieve the intended objectives.

The willingness to be open to new ideas; a positive attitude towards changes and uncertainty, and a spirit of perseverance helped to overcome the initial fear and scepticism. While this e-Orientation was definitely not on the agenda, its successful conduct has opened our eyes to how it could offer a viable alternative to the tried and tested conventional face-to-face programme. The convenience, accessibility and flexibility of the online platform, together with suitably designed online activities differentiated this Orientation into a unique experience, and possibly resulting in high participation rates among the freshmen.

With an eye on the future, the knowledge learnt through this experience can be passed on to the next batch of junior Orientation leaders, and may also come in helpful should we be involved in the organisation of online versions of regional events, such as the Asia-Pacific Dental Students Association (APDSA) conference, in the future. On a more personal note, this experience has also made each one of us more cognisant of pertinent issues inextricably linked to the use of social media, such as security and privacy, and will shape our behaviour on online platforms in the future as well.

If asked whether we would do this all over again, we would gladly step forth with a resounding Yess!!!

Notes on Contributors

Teng Chun Koh directed the project, reviewed literature and took the lead in writing and editing the manuscript.

Eugene Zhi Jie Lee contributed to the design of the project and ideas for this manuscript.

Charlene Jie Lin Yak contributed to the design of the project and ideas for this manuscript.

Jack Botao Sun contributed to the ideas for the project and this manuscript.

Joshua Ren Wei Tay was invited to make some brief corrections to the manuscript.

Ann Chong Hui Fong advised and provided feedback on the manuscript, aiding development of the manuscript.

Clara Yuen Pun Mok advised and provided feedback on the manuscript, aiding development of the manuscript.

All authors discussed and contributed to the final manuscript.

Acknowledgement

This e-Orientation could not have been successfully carried out without the support and encouragement from fellow classmates and friends, who hosted the e-Orientation games and activities with enthusiasm and passion. Their hard work indubitably contributed to the success of the event.

Funding

The authors have no funding to report. 

Declaration of Interest

The authors have no conflict of interest to declare.

References

Ullman, E. (2020, October 27). How to take college orientation online. https://www.techlearninguniversity.com/how-to/how-to-take-college-orientation-online

Zoom Communications Inc. (n.d.). Security: Zoom trust center. Retrieved January 26, 2021, from https://explore.zoom.us/en-us/trust/security.html

*Teng Chun Koh
9 Lower Kent Ridge Road, #10-01,
National University Centre for Oral Health,
Singapore 119085
Email: e0405935@u.nus.edu

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

Annushkha Sharanya Sinnathamby

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

I. INTRODUCTION

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

William Osler

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

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

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

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

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

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

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

II. ARE OUR VALUES MISPLACED?

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

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

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

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

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

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

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

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

1) If they had ever lied to get a scan

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

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

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

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

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

III. WHAT VALUES SHOULD WE VALUE?

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

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

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

IV. HOW SHOULD WE VALUE OUR VALUES?

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

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

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

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

Note on Contributor

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

Acknowledgements

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

Funding

There was no funding involved in writing this article.

Declaration of Interest

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

References

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

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

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

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

Submitted: 12 July 2020
Accepted: 18 August 2020
Published online: 5 January, TAPS 2021, 6(1), 122-124
https://doi.org/10.29060/TAPS.2021-6-1/PV2339

Hirohisa Fujikawa¹, Daisuke Son^1,2 & Masato Eto¹

¹Department of Medical Education Studies, International Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Japan; ²Department of Community-based Family Medicine, School of Medicine, Tottori University Faculty of Medicine, Japan

I. INTRODUCTION

Many countries enforce limits on the number of hours that medical residents work. For example, in the United States, regulations about duty hours were instituted by the Accreditation Council of Graduate Medical Education as early as in 2003, reinforcing those limits in 2011 and again in 2017 (Accreditation Council for Graduate Medical Education, 2017). These reforms triggered discussion in medical education literature about their wide-ranging effects on resident education, resident wellness, and patient care (Bolster & Rourke, 2015).

In Japan, restrictions on working hours will be implemented for physicians in April 2024 (Shibuya & Unno, 2019). Because of its rapidly shifting demographics to being a super-aged society with a low birth rate, Japan is now facing issues with residents’ learning and working that other countries will need to confront in the near future as their populations shift as well (as of late 2020). Here we report on the history and current situation of postgraduate medical education in Japan, which are highly relevant to re-evaluating postgraduate training in other countries.

II. INTRODUCTION OF WESTERN-STYLE MEDICAL EDUCATION TO JAPAN

Up to and throughout the Edo period (1603–1868), there were no qualifications required for someone to become a physician; they learned in apprenticeship or learned by reading medical books on their own (Izumi & Isozumi, 2001).

At the beginning of the Meiji era (1868–1912), the Japanese government introduced German medicine to the medical education system in Japan. In 1871, the government invited German medical teachers to the precursor of the University of Tokyo (Daigaku To-ko) (Izumi & Isozumi, 2001). In the years that followed, many graduates from that school were in charge of medical education at medical schools nationwide. The German-style medical education system, therefore, spread throughout Japan and the German impact on the Japanese system of medical education is still evident. For example, Japan’s current six-year undergraduate medical educational system has Germanic origin. Thus, although Japan introduced Western-style medical education, there was no systematic system of postgraduate medical education in this era.

III. EARLY INTERNSHIP PROGRAMME AND DEVELOPMENT OF NEW POSTGRADUATE MEDICAL TRAINING SYSTEM

From the end of World War II until the 1980s, the Japanese medical education system was reconstructed as a result of Japan coming under American influence. In 1946, the present national licensing system for physicians and first medical internship system were implemented. The educational content of this early internship programme, however, was lacking, as were the financial arrangements for the interns. Trainees had no guarantee of their status, and the first-year residents were required to work as volunteers before taking the national medical license examination (Shukan Igakukai Shimbun, 2004).

In the late 1960s, protests by medical students at the University of Tokyo for the improvement of interns’ working conditions progressively intensified and spread to other universities as well. Students across the country boycotted the medical license test and those in Tokyo occupied the Yasuda Auditorium (a symbol of the University of Tokyo) in protest. There was recognition that the internship programme as it was, with its overworked trainees, could lead to patient safety issues related to possible errors by the fatigued interns. This problem of patient safety is still a topic of discussion worldwide, and led to the limit of 80 hours of work per week for residents in U.S. training programmes mentioned in the introduction.

As a result of the protest, the internship system was discontinued in 1968, and a postgraduate medical training system was introduced to replace it. In this system, students took the medical license examination following graduation, and then received specific training for at least two more years. This strengthened the quality of the education compared to the previous system, but the status and pay of the trainees remained unstable (Shukan Igakukai Shimbun, 2004). Graduate students were forced to work part-time jobs during their training. They also raised issues related to the content of their education, inadequate guidance system, and insufficient evaluation of the training received.

In 2004, a new two-year mandatory postgraduate medical training system was implemented in all training programmes (Shukan Igakukai Shimbun, 2004). In this system, all medical school graduates spend two years rotating through the seven specialties (internal medicine, surgery, emergency medicine or anaesthesiology, paediatrics, psychiatry, community-based medicine, and obstetrics and gynaecology). Then only after the two-year training, can young physicians enter specialty-based residencies. Owing to this reform, the average resident salary has increased, and residents are paid sufficiently to concentrate on their training. Moreover, with respect to learning, this system has enabled residents to obtain more experience and become more confident about their clinical skills and the efficiency of their general knowledge (Nomura et al., 2008).

 IV. WORK STYLE REFORM

The Japanese economy grew dramatically after World War II. At that time, ideal workers were considered to be those who spent all their time working. The epitome of this attitude is captured in the phrase “Can you work for 24 hours?” which became popular after originating from a Japanese TV advertisement for an energy drink. Japan was notorious for its long working hours, and because it also became an aging society, where a relatively small number of working-age people must support a large senior population, there was a need to raise productivity. Death by overworking was so frequently occurring in Japan that it even had its own name, Karoshi, which literally means “death by overwork.” As a result, work-life balance started to get a lot of attention as the solution to avoid this social problem.

Medical care in Japan has long been supported by the self-sacrificing work of physicians, especially young doctors in their twenties and thirties (Shibuya & Unno, 2019). According to an investigation performed by the Ministry of Health, Labour and Welfare (MHLW), 40% of physicians exceed the norm for hours worked by workers in other sectors. More than 10% of physicians work more than 1860 hours of overtime per year (Ministry of Health, Labour and Welfare, 2019). Because of this, the MHLW drew up a contentious plan to restrict physicians’ working hours through a regulation that will take effect in 2024. In particular, physicians’ overtime hours will be restricted to 960 hours per year, to keep hours below what is called the “Karoshi Line” (the number of hours beyond which a death is presumed to be related to overwork). There will still be allowances in the regulation for some physicians to work up to 1,860 hours yearly overtime, far above the Karoshi Line, if necessary to maintain community health care or to work intensively for the purpose of learning and becoming specialists.

V. RESIDENT AS LEARNER OR WORKER?

In Japan, the view of residents has vacillated over time between the perspective of “resident as learner” and that of “resident as worker.” Until the repeal of the early internship system in 1968, the viewpoint of “resident as learner” was dominant, and trainees were obliged to work unpaid. In the course of abolition of the early internship system, the standpoint of “resident as worker” was enhanced. The perspective of “resident as learner” was revisited through the process of the new two-year postgraduate training system implementation in 2004.

Nowadays, the viewpoint of “resident as worker” draws attention because physicians and residents are still forced to work for prolonged hours. Because of this, burnout among medical residents has become a critical problem, and several studies have been conducted on the mental health of residents in Japan. This suggests that the pendulum has swung too far and the perspective of “resident as learner” is now lacking. We must develop and implement resident education that emphasises their roles as both learners and workers, for the sake of the patients they care for and for society’s sake.

The implication of this is that we will need to educate residents effectively and efficiently within a limited number of work hours. The duty hour restrictions will raise the number of trainees caring for a particular patient on any given day, and will push up the demand for meaningful and efficient transfer of information. We will have to teach “new professionalism.” New professionalism derives from sharing responsibility for patient care, as contrasted with nostalgic professionalism, which is defined as continuously giving priority to a patient’s needs over one’s own personal needs (Arora, Farnan, & Humphrey, 2012). Trainees have to be taught a new view of their responsibilities and new skills for directing team-based care. More specifically, they should be taught the skills of quickly summarising and communicating pertinent sign-out information at the end of shifts to support patient care. The model of continuity-enhanced handovers may be useful (Arora, Reed, & Fletcher, 2014).

It is our responsibility as educators and leaders to seek breakthrough solutions to promote an educational system that emphasises both the perspective of “resident as learner” and that of “resident as worker.” It is time for change.

Notes on Contributors

Hirohisa Fujikawa contributed to the acquisition, analysis and interpretation of the data and the drafting of the manuscript. He approved the final manuscript, and agreed to be accountable for all aspects of the work in ensuring that questions related to any part of the work are appropriately investigated and resolved.

Daisuke Son contributed to the conception and design of the study, and the revision of the manuscript. He approved the final manuscript, and agreed to be accountable for all aspects of the work in ensuring that questions related to any part of the work are appropriately investigated and resolved.

Masato Eto contributed to the conception and design of the study, and the revision of the manuscript. He approved the final manuscript, and agreed to be accountable for all aspects of the work in ensuring that questions related to any part of the work are appropriately investigated and resolved. 

Acknowledgement

The authors wish to express sincere appreciation to Ms. Kayo Kondo, School of Politics, Philosophy, Language and Communication Studies, University of East Anglia, who assisted us in translating the manuscript.

Funding

The authors have no funding to report.

Declaration of Interest

The authors declare no conflicts of interest associated with this manuscript.

References

Accreditation Council for Graduate Medical Education. (2017). Common Program Requirements Section VI with Background and Intent [PDF file]. Retrieved from https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_Section%20VI_with-Background-and-Intent_2017-01.pdf.

Arora, V. M., Farnan, J. M., & Humphrey, H. J. (2012). Professionalism in the era of duty hours: Time for a shift change? JAMA, 308(21), 2195–2196. https://doi.org/10.1001/jama.2012.14584

Arora, V. M., Reed, D. A., & Fletcher, K. E. (2014). Building continuity in handovers with shorter residency duty hours. BMC Medical Education, 14(Suppl 1), S16. https://doi.org/10.1186/1472-6920-14-S1-S16

Bolster, L., & Rourke, L. (2015). The effect of restricting residents’ duty hours on patient safety, resident well-being, and resident education: An updated systematic review. Journal of Graduate Medical Education, 7(3), 349–363. https://doi.org/10.4300/JGME-D-14-00612.1

Izumi, Y., & Isozumi, K. (2001). Modern Japanese medical history and the European influence. The Keio Journal of Medicine, 50(2), 91–99. https://doi.org/10.2302/kjm.50.91

Ministry of Health, Labour and Welfare. (2019). On the upper limit for overtime among doctors (in Japanese). Document 2 presented at the 19th Committee on the Work Style Reform of Doctors [PDF file]. Retrieved from https://www.mhlw.go.jp/content/10800000/000481338.pdf

Nomura, K., Yano, E., Aoki, M., Kawaminami, K., Endo, H., & Fukui, T. (2008). Improvement of residents’ clinical competency after the introduction of new postgraduate medical education program in Japan. Medical Teacher, 30(6), e161–e169. https://doi.org/10.1080/01421590802047307  

Shibuya, K., & Unno, N. (2019). Unpaid doctors in Japanese university hospitals. The Lancet, 393(10176), 1096–1097. https://doi.org/10.1016/S0140-6736(19)30472-6

Shukan Igakukai, Shimbun. (2004). The History of clinical training in Japan (in Japanese) [PDF file]. Retrieved from http://www.igaku-shoin.co.jp/nwsppr/n2004dir/n2566dir/n2566_02.pdf

*Hirohisa Fujikawa
The University of Tokyo,
7-3-1 Hongo, Bunkyo-ku,
Tokyo 113-0033, Japan
Tel: +81-3-5841-3480
Email: hirohisa.fujikawa@gmail.com

Submitted: 1 April 2020
Accepted: 26 May 2020
Published online: 5 January, TAPS 2021, 6(1), 128-131
https://doi.org/10.29060/TAPS.2021-6-1/PV2240

Sonia Kumar, Rachel Browne, Jeffrey Wu & Simon Tso

Department of Dermatology, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom

I. FACTORS INFLUENCING MOTIVATION TO PURSUE GRADUATE-ENTRY MEDICINE

The decision to pursue medicine is a significant step for individuals, particularly those for whom this involves a career change. While medicine in the UK has traditionally been an undergraduate course, graduate-entry medicine (GEM) programmes were introduced in 2000 and offer an accelerated course for suitably qualified candidates with a Bachelor’s degree. Students have a variety of motivations for undertaking a GEM programme (Carter & Peile, 2007), and we herein explore the factors that influence this range of motivations.

Literature suggests that students of GEM programmes can broadly be categorised into two groups: individuals who do not consider medicine when choosing their first degree, or individuals who selected a degree subject that would keep medicine open as a career (Sulong et al., 2014). Key motivating factors to pursue GEM include prior health service experience (as a patient or as a health professional), professional autonomy, and influence from others. The most frequently cited factor influencing the decision was a desire to help people (Sulong et al., 2014). Other literature suggests a lack of job satisfaction and limited career development opportunities are key factors drawing individuals away from their original career paths and into medicine.

The other group includes individuals who had previously failed to gain entry to medical school at the undergraduate level, studying alternative subjects but maintaining a goal of studying medicine. These individuals have demonstrated motivation by completing a degree that was not their first choice, and this can continue throughout their medical studies. A comparison of Leicester Medical School GEM and undergraduate-entry medicine (UEM) students found higher general pass rates for GEM students with a biomedical science background when compared to their UEM peers (Carter & Peile, 2007).

II. STUDENT EXPERIENCES

A semi-structured interview-based study exploring the experiences of twenty-one students from the University of Warwick GEM programme was conducted by the author Simon Tso as part of his doctoral research thesis (Tso, 2017). Students were asked to describe their motivations to pursue GEM. Three broad groups of student journeys into GEM were identified: ‘medicine as an end goal’, ‘career indecision’ and ‘career switchers’. The ‘medicine as an end goal’ group represented students within the study and students in this group recalled a longstanding ambition to pursue medicine. The ‘career indecision’ group consisted of students who had previously considered medicine as a potential career but instead chose an alternative path. The ‘career switchers’ comprised of students who left their previous career to pursue GEM.

 A. Why Pursue Medicine as a Career?

Motivations to pursue GEM were attributed to a combination of ‘pull’ and ‘push’ factors. ‘Pull’ factors included those that the students regarded as positive experiences or perceived incentives of choosing medicine as a career. A few, however, experienced negative ‘pull’ factors, recalling pressure and expectation from family to pursue medicine simply because they were good at science. Often, the reassurance of a guaranteed job following the degree influenced this pressure.

A key theme for motivations reported by this group was their general interest in human health, a desire to improve people’s lives and to do “meaningful work”. In most instances, many had received positive encouragements from other individuals who supported and positively influenced their career choice. One student, however, recalled a negative experience in secondary school when he expressed an interest in applying for UEM to a teacher. This teacher subsequently discouraged application expressing that they did not believe the student would meet the expected entry requirements. The student felt that extra support from their teachers rather than discouragement could have guided them to have studied UEM rather than having to apply for a GEM programme later in life.

‘Push’ factors were reasons why some students chose to cease continuing on their original career path and consider alternative careers instead. Reasons given highlighted the disillusionment they felt with certain aspects of their original career path and therefore felt pushed to consider an alternative career. These included lack of career progression opportunities, lack of job satisfaction and lack of autonomy in their roles. The students perceived that medicine could offer the opportunities they desired from a career.

III. OUR REFLECTIONS

A. What Factors Influence Motivation to Study GEM?

The Self Determination Theory devised by Ryan and Deci (2000) can be applied to the understanding of why people choose to study GEM. The Self Determination Theory suggests that three factors are required for psychological growth: autonomy, competence and connection. Although thought to be innate, these factors are affected by environmental interactions and can influence our proactivity or passivity. The degree of self-determination is also influenced by whether the factors that motivate us are:

1. Intrinsic–where an activity is done for the pleasure or enjoyment of the activity itself.
2. Extrinsic–where a task is performed for a possible reward or fear of punishment.
3. In some instances, factors that make us demotivated–the lack of desire to act or, act without intent.

 

Typical intrinsic factors recalled as motivations for pursuing GEM were the desire to do something fulfilling or to help others. For others it was the desire to commit to lifelong learning or a career where their interest in biological sciences could be applied to human physiology.

Extrinsic factors such as family pressures or socioeconomic background also have been known to impact career choice and journey. In some cultures, professions such as medicine, engineering or pharmacy are held in high esteem and children from these backgrounds can be encouraged to pursue these subjects at university. These careers are often associated with job and financial stability, factors that may be of high importance to individuals from a disadvantaged or low socioeconomic background. In these instances, a career in medicine can be perceived as a mode of upwards social mobility.

B. What Factors Contribute to Career Indecision?

Gati, Krausz and Osipow (1996) describe a theoretically driven taxonomy of career decision that can be applied to the career indecisions reported by the medical students in their study. The taxonomy was categorised into three broad clusters; lack of readiness, lack of information, and inconsistent information, all of which can explain why individuals may be hesitant or indecisive when considering a career in medicine.

Typically, students in the United Kingdom consider a career in medicine aged 16-18, applying to medical school in the second year of the A-Level programme. The decision to pursue medicine is difficult, and some may be lacking the required information to adequately prepare them, both to apply and to succeed in the application process. This is particularly relevant to students from disadvantaged backgrounds or resource-poor schools that may find it challenging to support the aspirations of their students and prepare them for medical school interviews.

Widening participation (WP) is an umbrella term referring to coordinated efforts that encourage and support individuals from underrepresented or disadvantaged backgrounds to consider pursuing academic careers such as engineering, medicine and law. The idea behind the programmes is to ensure that all students have access to equal opportunities, regardless of their background. These schemes often provide interview support, work experience schemes and checking of personal statements. They can provide further insight into the career, and also provide workshops on the special entrance tests required for medical school admission.

A medical student in our study was supported by a WP scheme to gain admission into her first degree which served as a stepping-stone into a GEM programme. An increase in provision and access to WP schemes would seek to level the playing field in the application process to medical school at both UEM and GEM level. The provision of extra support and information would enable these students to make informed career choices and make the medical school application process fairer.

IV. CONCLUSION

GEM programmes provide individuals the opportunity to pursue medicine as a career at a later stage, and their additional life and work experience can engender a more diverse and experienced cohort of graduates (Carter & Peile, 2007). WP schemes at the university level could further contribute to this diversity, and it would be interesting for future studies to explore whether students who were unsuccessful or did not attempt to gain entry at the UEM level could have benefited from secondary school WP programmes.

It is clear that there are multiple reasons individuals decide to pursue GEM, whether as a long-term ambition from school age or as a career change. These multifactorial motivations consist of both intrinsic and extrinsic factors and more work is needed to understand their influence on students’ motivations. Identifying common themes allows for more effective recruitment and teaching of these non-traditional students who will eventually contribute to a more diverse medical workforce.                                

Notes on Contributors

Dr Sonia Kumar is a graduate of the University of Warwick graduate-entry medicine degree programme and is a newly qualified Foundation Year 1 doctor at the South Warwickshire NHS Foundation Trust. Dr Kumar made substantial contributions to the conception, design, editing of this piece and approval of the final manuscript.

Dr Rachel Browne completed a Masters in Medical Education at the University of Warwick. She is a Speciality Registrar in Dermatology and former Clinical Education Fellow at the South Warwickshire NHS Foundation Trust. Dr Browne contributed to the design and editing of this piece including approving this final manuscript.

Dr Jeffrey Wu is a graduate of the University of Warwick graduate-entry medicine programme and former undergraduate Teaching Assistant at the University of California, San Diego. He is training in Internal Medicine at South Warwickshire NHS Foundation Trust. Dr Wu contributed to the design, edit and approval of this manuscript.

Dr Simon Tso completed a doctoral (MD) degree at the University of Warwick. He is a Fellow of the Higher Education Academy and Consultant Dermatologist at the South Warwickshire NHS Foundation Trust. Dr Tso made substantial contribution to the conception, data analysis/interpretation editing and authorising the final manuscript.

Ethical Approval

This study was part of a larger study investigating the experience of graduate-entry medicine degree programme students, which has received ethical approval from the University of Warwick Biomedical Research Ethics Sub-Committee (Reference: 169-01-2012).

Acknowledgements

The authors would like to thank Asim Yousuf, Nina Owen, Mike Smith and Dr Jane Kidd for their assistance with the design and development of the study.

Funding

This study was part of a larger study investigating the experience of graduate-entry medicine degree programme students, which was funded by the Institute for Advanced Teaching and Learning, University of Warwick, United Kingdom.

Declaration of Interest

The authors have no conflict of interest, including no financial, consultant, institutional and other relationships that might lead to bias.

References

Carter, Y. H., & Peile, E. (2007). Graduate entry medicine: High aspirations at birth. Clinical Medicine, 7(2), 143–147. https://doi.org/10.7861/clinmedicine.7-2-143

Gati, I., Krausz, M., & Osipow, S. H. (1996). A taxonomy of difficulties in career decision making. Journal of Counselling Psychology, 43(4), 510–526. https://doi.org/10.1037/0022-0167.43.4.510

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. https://doi.org/10.1037/0003-066X.55.1.68

Sulong, S., McGrath, D., Finucane, P., Horgan, M., O’Flynn, S., & O’Tuathaigh, C. (2014). Studying medicine – A cross-sectional questionnaire-based analysis of the motivational factors which influence graduate and undergraduate entrants in Ireland. JRSM Open, 5(4), 204253331351015. https://doi.org/10.1177/2042533313510157

Tso, S. H. Y. (2017). The graduate-entry medical student: Challenges to transition through medical school (Doctoral dissertation, University of Warwick, Coventry, United Kingdom). Retrieved from http://wrap.warwick.ac.uk/99890/

*Sonia Kumar
Lakin Road, CV34 5BW
South Warwickshire NHS Foundation Trust,
Warwick, United Kingdom
Email: Sonia.kumar@doctors.org.uk

Submitted: 21 February 2020
Accepted: 3 June 2020
Published online: 5 January, TAPS 2021, 6(1), 125-127
https://doi.org/10.29060/TAPS.2021-6-1/PV2228

Chooi Peng Ong, Cindy Shiqi Zhu, Desmond SL Ong & Ying Pin Toh

Family Medicine Residency, National University Health System, Singapore

I. INTRODUCTION

Family medicine training encompasses the need to develop a diverse skillset and the ability to practice in different settings. During three years of training, family medicine residents from National University Health System (NUHS) rapidly transit through many hospital rotations with varying specialty-specific competency requirements. Throughout this period, each resident is rostered to run a half-day primary care clinic on the same day each week and is assigned a dedicated faculty member to supervise him during the session. Each faculty member is assigned up to four to six residents for the half-day sessions every week.  There is a need to contextualise what is learnt in hospital to primary care, and to effectively integrate knowledge across disciplines. We describe here a tool that the NUHS family medicine residency has used to bring together faculty and residents of varying seniorities and locations for discussion, reflection, and growth.

II. METHODS

A. What We Did

Over the past few years, learners’ groups have been created by residency faculty and residents on a voluntary basis, using an internet-based group messaging platform. As described here, the group is defined by a common supervising faculty member and is formed for the duration of the academic year. The supervisor is also the group administrator and main facilitator.

The platform described here is the WhatsApp messaging platform. It was chosen because of the ubiquity of its use by the faculty and resident bodies as well as the closed nature of the groups, in that membership is by invitation, and messages are encrypted (WhatsApp Inc., n.d.). An additional benefit was that, unlike some dedicated healthcare messaging applications, the messages and shared resources are not automatically deleted (Geron, 2011) after a period of time.

The WhatsApp group chat functions as a virtual community board for clinical learning, questions, answers, and clarification. Topics discussed usually arise from residents’ clinic encounters, and the emphasis of discussion is on contextualising knowledge from books and hospital learning to real-life primary care practice. For example, a patient is seen for chronic disease management and is noted to smoke cigarettes. The post-consultation debrief may include a suggestion to read up on nicotine replacement strategies (NRT), following which the resident may upload an update on NRT to the chat group. Case-based discussion proceeds asynchronously and is facilitated by the supervisor and contributed to by all group members. Notably, case discussions involving patients are anonymised, and the use of unique personal identifiers is prohibited. Additionally, the group platform allows discussion and opinion to evolve on current issues relating to professionalism and ethics. Over time, the group chat messages become a useful depository of contextualised, opportunistic, experiential learning for the group.

III. DISCUSSION

A. Potential Pitfalls

The commonest pitfall is the tendency for resources shared to be comprehensive textbook-like knowledge updates, whereas the more useful type of update is a distilled, pragmatic one that can be directly applied to practice. It is often noted that group participation tends to wane as the year progresses, possibly due to an increase in coursework and examination preparation. Some group members tend to participate more freely than others. Unlike a face-to-face group, the quiet members may be virtually forgotten by others over the course of the year unless effort is made to engage them.

The openness of the discussion can be affected by traditional medical hierarchies and the facilitator may need to intentionally address this. It is important to recognise that the richness of discourse is largely dependent on the quality of moderation and on participant engagement. Finally, as topics for discussion are identified opportunistically, the same topics may be repeatedly identified.

B. Tips for Managing the Group

The tone and culture of the group will greatly affect the efficacy of group interactions. It is important to set ground rules of courtesy, freedom to question, and expectations of participation early in the group’s life cycle. Also, while the facilitator needs to encourage active participation with provocative questioning, the senior residents need to help set the tone of egalitarian discussion, in order for younger participants to feel sufficiently comfortable to contribute willingly. Having a co-facilitator who is another faculty member or a resident who was a member of a past-year group has helped in establishing the group’s openness and activeness, with varying degrees of success.

It is important for the facilitator to have an idea of what broad topics ought to be discussed over the lifespan of the group, which is often the duration of the academic year. This ensures that discussions are guided beyond the strictly opportunistic. The length of contributions should not exceed the attention span of those reading. As a suggestion, the length of an uploaded update should not exceed the size of a smartphone screen, the emphasis being on curated pearls.

It is important to emphasise an academic focus, to ensure the group does not devolve into a social support group. This is not because social support is secondary, but because these WhatsApp groups, as described here, were set up to further academic objectives. Social greetings are therefore largely relegated to alternative message boards and private messages. Nevertheless, it is recognised that a functional group will have social elements, and that social greetings may be an indicator of group cohesion and viability (Salas, Grossman, Hughes, & Coultas, 2015).

As with any group that interacts over time, an informal curriculum (Rogoff, Callanan, Gutiérrez, & Erickson, 2016) will run in parallel with the explicit curriculum and will eventually impact on learner attitudes and even values. It is important for the facilitator to reflect on the elements of his informal/implicit curriculum and to intentionally drive it. Examples of these elements may include personal integrity, collegiality, or independent questioning.

IV. CONCLUSION

The WhatsApp chat groups described here have allowed us to extend study group discussions beyond the clinic. This is particularly useful in family medicine training where the contextualization of a broad knowledge base needs to be constant and relentless, and opportunities for face-to-face meetings are limited by logistics.  The extended virtual discussion is also a useful platform by which to teach affective domain skills, such as attitudes and values. Because of the iterative nature of clinic sessions intercalated with online discussions, learning can be reflected on and applied and may be postulated to occur at up to Kirkpatrick level 3 (Kirkpatrick & Kirkpatrick, 2006). Finally, by bringing together learners of varying seniorities, role modelling, mentoring, camaraderie, and certain emotional support are happy by-products. 

Notes on Contributors

Ong Chooi Peng is a faculty member of the NUHS family medicine residency program. She runs several virtual groups, reviewed the literature, and wrote the manuscript.

Desmond Ong is a faculty member of the NUHS family medicine residency program. He also runs virtual groups and helped edit the manuscript.

Cindy Zhu Shi Qi and Toh Ying Pin are residents within the NUHS family medicine residency program. They belong to virtual groups and helped edit the manuscript.

Acknowledgements

The authors acknowledge the generations of NUHS family medicine residents who have contributed to the development and evolution of the virtual groups, to the current form of WhatsApp groups described here.

Funding

The authors received no funding for this work.

Declaration of Interest

The authors declare no conflict of interest.

References

Geron, T. (2011, June 15). TigerText secures (and erases) your text messages. Retrieved January 20, 2020, from https://tigerconnect.com/newsroom/tigertext-secures-and-erases-your-text-messages/ 

Kirkpatrick, D. L., & Kirkpatrick, J. D. (2006). Evaluating Training Programs. New York, NY: Macmillan Publishers.

Rogoff, B., Callanan, M., Gutiérrez, K., & Erickson, F. (2016). The organization of informal learning. Review of Research in Education, 40(1), 356-401. https://doi.org/10.3102/0091732×16680994

Salas, E., Grossman, R., Hughes, A., & Coultas, C. (2015). Measuring team cohesion. Human Factors: The Journal of the Human Factors and Ergonomics Society, 57(3), 365-374. https://doi.org/10.1177/0018720815578267

WhatsApp Inc. (2020, January 20). WhatsApp Security: Privacy and Security is in our DNA. Retrieved from http://www.whatsapp.com/security/

*Cindy Shiqi Zhu
1E Kent Ridge Road,
Singapore 119228
National University Health System (NUHS)
Email: Shi_Qi_ZHU@nuhs.edu.sg

I. INTRODUCTION

Big data (BD) involves aggregating and melding large and heterogeneous datasets, allowing searches and cross-referencing, and deriving insights and meaning from them. It has tremendous potential for application in medical education (ME) where the massive amounts of data that are generated and collected about learners, their learning, and the organisation of their learning can be analysed and interpreted to provide meaning and insights into various aspects of ME. This article briefly introduces BD, potential areas of application, and highlights the pitfalls and challenges surrounding the use of BD in ME (BDME) from the authors’ perspectives.

II. BIG DATA IN MEDICAL EDUCATION (BDME)

The concept of BD has its origins in commercial industries, and also academic and technical disciplines (e.g., astronomy and genomics) where enormous amounts of complex data and information are routinely collected, managed and analysed (Ellaway, Pusic, Galbraith, & Cameron, 2014; Schneeweiss, 2014). This information possesses characteristics denoted by the four Vs: high Volume, Variety, Velocity, and Veracity (validity); conventional database software tools are unable to fully capture, store, process, or analyse them (Ellaway et al., 2014). BD is relatively new in clinical medicine and applying BDME has been slow and limited (Cook, Andriole, Durning, Roberts, & Triola, 2010; Ellaway et al., 2014) Nonetheless, in the last few years, there are increased efforts to apply BD to ME (Chahine et al., 2018; Ellaway et al., 2014). To this end, ME is well suited for BD application as a massive volume of complex data is generated and collected constantly from different programs and educational institutions, and from multiple sources, both structured and unstructured: e.g., electronic medical records, assessment results and test scores, evaluation and feedback information, as well as curriculum and program evaluation (Chahine, et al., 2018; Cook et al., 2010). By harnessing the power of BDME, information and data can be aggregated, integrated, and analysed, then interpreted and acted on if necessary (Ellaway et al., 2014; Schneeweiss, 2014).

III. POTENTIAL APPLICATIONS OF BDME

The potential of BDME includes both practical (e.g., program and curriculum assessment and evaluation) and research applications. Depending on the purpose and/or research question, the data mining may be on a broad, systems-level or a personalised small-scale basis. BDME application organises and crystallises the data to enable a better understanding of and insight into what happened, and what is currently happening. This may occur through various different ways of analyses including prospective longitudinal analysis, trend discovery, pattern recognition and predictive analytics. Hence, predictions or extrapolations might be made in regards to what may yet happen in curriculum, programs and educational practices (Chahine et al., 2018; Cook et al., 2010; Ellaway et al., 2014).

For instance, BDME can facilitate decision-making in undergraduate ME, e.g., entry selection of medical students, or readiness of a medical student to graduate. In postgraduate ME, BDME can provide insights into data on learners’ experience and exposure, feedback information, as well as assessment data within and across programs (Chahine et al., 2018; Ellaway et al., 2014). This allows personalised feedback and individualised learning plans (Chahine et al., 2018), and facilitates the implementation of entrustable professional activities (EPA). Learning gaps and teaching lapses can also be identified to support improvement or changes to certain practices or contents. Applying BDME on these educational and other data (such as demographics, admission criteria or educational practices) in a longitudinal and cross-sectional manner allows benchmarking and accountability across different cohorts, programs, and institutions. This is vital for continuous quality assurance and improvement of ME practices (Chahine et al., 2018; Cook et al., 2010; Ellaway et al., 2014), or for evaluation of upstream policies (Chahine et al., 2018; Schneeweiss, 2014). These same processes can also be performed across countries to inform ME from international or cross-cultural perspectives.

Another potential application of BDME is to investigate the (hitherto assumed) link between ME and patient care. Drawing on combined data from educational and clinical information repositories (e.g., correlating patient outcomes from hospital and clinic health information systems with different models of educations within and across institutions), one would be able to evaluate if, and to what extent, educational practices translate into improved health care outcomes for patient and society (Chahine et al., 2018). One example is the Jefferson Longitudinal Study of Medical Education (Callahan, Hojat, Veloski, Erdmann, & Gonnella, 2010) whereby data on 8000 students who were tracked over 40 years showed that MCAT examination performance is a valid predictor of medical school and residency performance. This and other studies confirmed the feasibility and utility of applying BD to inform current medical educational practices, and to bridge the gap between pedagogical theory and practice. Further, by enabling a longitudinal view of physicians’ progression and development through their education, and the career choices made, BDME can provide information and evidence to facilitate recommendations for important strategic policies and decisions, e.g., manpower planning or speciality development. These are subjects of interest for policy-makers, regulatory authorities, medical educators and researchers.

IV. POTENTIAL OBSTACLES AND PITFALLS

Whilst there are many potential fruitful applications of BDME, some challenges and issues must be critically addressed before the widespread adoption of BD into mainstream ME practice.

Data fragmentation, so common in healthcare systems, is a major obstacle to the widespread use of BDME (Ellaway et al., 2014; Schneeweiss, 2014). For a start, electronic health or medical records (EMR) are frequently incompatible and heterogeneous across hospital systems that store the data (Chahine et al., 2018; Ellaway et al., 2014). Practice standards and vocabulary are also not standardised. Also, healthcare systems are not required (or willing) to exchange and share data with each other. In addition, organisational policies regarding security and confidentiality limit data accessibility (Chahine et al., 2018; Ellaway et al., 2014). Further, there are ethical and medicolegal considerations. For instance, most of the patient data captured on EMR was not originally intended for education purposes, and does not include informed consent in this respect. Even if the data can be anonymised with identifiers removed, questions remain on what data is collected, how the data is stored and protected, how it is used and shared – by whom, and with whom. These issues extend to ME data too; confidentiality issues and access restrictions to data collected on learners, programs and institutions can limit the quality, analysis and value of BDME.

Hence, government and health authorities, EMR companies, hospitals and training institutions must cooperate to improve medical data and information systems, and strengthen data exchange and integration across organisations (Chahine et al., 2018; Cook et al., 2010; Ellaway et al., 2014). Appropriate legislations or policies may be necessary. Investments in infrastructure, technologies and expertise to manage and protect data from different sources are also needed. The infrastructure and technological expertise (for collection, storage, processing and analysis) could be centralised in a ‘data warehouse’ – different institutions become data providers to this ‘central’ BD collective (Cook et al., 2010; Ellaway et al., 2014). It is likely that external partners (e.g., data science, informatics) will be involved to facilitate and optimise the use of BD. Under these circumstances, the governance, ownership of, and access to data are important issues to consider.

In using BDME to correlate training and clinical care outcomes, the challenge is being able to accurately link a learner’s (or a cohort of learners’) education and training with patient-level or system-level clinical outcomes (Chahine et al., 2018; Cook et al., 2010). Given that multiple healthcare providers (students, residents, practicing physicians) may be involved in the care of a particular patient, innovative data analytical algorithms or techniques will be necessary in order to identify or ‘tag’ different aspects of clinical care or patient encounters, and accurately attribute these to specific providers over prolonged periods of time, and across institutional, clinical and educational boundaries (Chahine et al., 2018; Cook et al., 2010). If successful, this will provide unprecedented potential for performance assessment and evaluation.

The application of BDME also has inherent limitations and fallibility (Chahine et al., 2018; Ellaway et al., 2014). The interpretations and conclusions (and the subsequent decisions and actions) based on BDME must be made with extreme caution. The standards and rigours of academic and scientific research must be applied and met – in the collection methods, precision, representativeness of data. There is intrinsic bias in BD due to the fact that information that cannot (or simply are not) be captured may be undervalued or ignored. Predicting trends and judging current and future potential and success of individuals or programs must similarly be tempered with caution (Chahine et al., 2018; Cook et al., 2010). Major decisions (especially summative) must be based on time-honoured, empirically proven principles: multiple data points, from multiple sources (triangulation), at different time points (reiterative), and after considering the dynamic nature of learning and education in reality.

There are real risks to the individuals and systems if BDME is used out of context, or for unintended purposes. For instance, should BDME be used to alter a learner’s (or a group of learners’) career path or choice? Should we judge learners based on ‘normal’ patterns of learner behaviour derived from BDME? Also, from the faculty’s perspective, it is tempting to use only those educational interventions that were ‘shown to work’ by BDME, at the expense of all others.

This article is not intended to propose solutions to the many issues surrounding the use of BDME. The permeation of BD into ME appears inexorable. It is time for the ME community to take the lead to critically appraise and shape the conversation surrounding BDME, so as to set the agenda and direction for the best use of BDME.

Notes on Contributors

Heng-Wai Yuen is an adjunct Associate Professor with the Duke-NUS Medical School and the Singapore University of Technology and Design (SUTD). He is the Director of Otology and Hearing Implants in the Department of Otolaryngology-Head & Neck Surgery, and the Deputy Director of Undergraduate Medical Education at Changi General Hospital.

Abhilash Balakrishnan is an adjunct Associate Professor with the Duke-NUS Medical School and Clinical Associate Professor with the Yong Loo Lin School of Medicine at the National University of Singapore. He is also the Deputy Head of Department (Education) in the Department of Otolaryngology at Singapore General Hospital.

Funding

The authors declare no funding is involved for this paper.

Declaration of Interest

The authors declare no conflict of interest.

References

Callahan, C. A., Hojat, M., Veloski, J., Erdmann, J. B., & Gonnella, J. S. (2010). The predictive validity of three versions of the MCAT in relation to performance in medical school, residency, and licensing examinations: A longitudinal study of 36 classes of Jefferson Medical College. Academic Medicine, 85(6), 980-987. https://doi.org/10.1097/ACM.0b013e3181cece3d

Chahine, S., Kulasegaram, K., Wright, S., Monteiro, S., Grierson, L. E., Barber, C., … Touchie, C. (2018). A call to investigate the relationship between education and health outcomes using big data. Academic Medicine, 93(6), 829-832.  https://doi.org/10.1097/ACM.0000000000002217

Cook, D. A., Andriole, D. A., Durning, S. J., Roberts, N. K., & Triola, M. M. (2010). Longitudinal research databases in medical education: Facilitating the study of educational outcomes over time and across institutions. Academic Medicine, 85(8), 1340-1346. https://doi.org/10.1097/ACM.0b013e3181e5c050

Ellaway, R. H., Pusic, M. V., Galbraith, R. M., & Cameron, T. (2014). Developing the role of big data and analytics in health professional education. Medical Teacher, 36(3), 216-222.      https://doi.org/10.3109/0142159X.2014.874553

Schneeweiss, S. (2014). Learning from big health care data. The New England Journal of Medicine, 370(23), 2161-2163. https://doi.org/10.1056/NEJMp1401111

*Heng-Wai Yuen
Changi General Hospital,
2 Simei Street 3, Singapore 539889
Tel: +65 69366259
Email: yuen.heng.wai@singhealth.com.sg