IV. CONCLUSION

Innovation in medical education is urgently needed. For decades, we have spent time and resources appreciating the most appropriate teaching strategy or way to assess our learners. We have now reached saturation in this regard. There is no one optimum way to teach a learner and no single optimum assessment method. What we now need is a stronger focus on healthcare deficiencies at a time where healthcare provision remains heavily invested in technology. Critics may highlight concerns allied to faculty resources, training of faculty as well as accreditation. However, it is our duty as educators to ensure our patients benefit from future doctors who have been trained in accordance with how healthcare is evolving. With expert clinicians and engineers already highly trained and guiding such programmes, full accreditation can be gained. The future is now not just clinical care but clinician engineering.

Notes on Contributors

NS is the founder of the clinician engineer hub and a clinician academic in gastroenterology.

MSB is a co-founder of the clinician engineer hub and lecturer in biophotonics.

AKY is a co-founder of the clinician engineer hub and senior lecturer in chemical engineering.

RM is a PhD candidate in biomedical engineering and instructor for the clinician engineer hub.

NS, MSB, AKY, and RM contributed to the article equally and agreed on the final version for submission.

Funding

The authors declare no funding is involved for this paper.

Declaration of Interest

The authors declare no conflict of interest.

References

Hall, H. (2019, January 15). Critical thinking in medicine. Science-Based Medicine. Retrieved from                  https://sciencebasedmedicine.org/critical-thinking-in-medicine

Patel, K. (2013). Is clinical examination dead? BMJ, 346, f3442. https://doi.org/10.1136/bmj.f3442

*Neel Sharma
Department of Gastroenterology,
Queen Elizabeth Hospital Birmingham,
Mindelsohn Way, B15 2TH
Tel: 0121 371 2000
Email: n.sharma.1@bham.ac.uk

I. INTRODUCTION

Most medical education programmes in Taiwan accept students upon high school graduation. Medical education used to consist of seven years with the last year being an internship. Since 2013, medical students have graduated at the end of six years, and the internship has been moved to a postgraduate year. In both formats, students have been offered medical humanities courses in the “pre-med” phase, i.e. the first two years of medical school. From the third year onward, however, students rarely have exposure to subjects related to humanism, other than courses on medical ethics and some problem-based learning case discussions. Moreover, medical students have had very little exposure to humanities in high school. Such limited exposure to humanities during medical school can have detrimental effects on cultivating humanistic physicians in Taiwan.

It is known that the majority of medical schools in the U.S. are post-baccalaureate system, i.e. most of the medical students have already had exposure to humanities courses during undergraduate years. Yet research shows that medical students in the U.S. have problems with empathy decline as they advance through medical school (Neumann et al., 2011). The Arnold P. Gold Foundation has been advocating for infusing the human connection into healthcare, and Plant, Barone, Serwint, & Butani (2015) articulated very well the need to take humanism back to the bedside. Lacking these efforts, the empathy decline among medical students in Taiwan could conceivably be even more serious than in the U.S.

This paper advocates for the importance of instilling humanism at the bedside during clinical rotations to serve as “booster shots” to enhance the medical humanities learned by students in the pre-med phase.

II. MY PERSONAL EXPERIENCES IN LEARNING AND TEACHING AT THE BEDSIDE

Following my graduation from medical school at National Taiwan University School of Medicine in 1969, I completed a four-year residency in the Neurology & Psychiatry Department at Taiwan Medical University Hospital (1970-1974) and did an attending year before I went to the University of Minnesota to start another residency program in Neurology (1975-1978). In Minnesota, I was deeply impressed by the bedside teaching of my respected mentor, Dr. A. B. Baker, the chairman of the Neurology Department. I vividly remember one unforgettable incident – before he did a “straight leg raising test” (Swartz, 2014) on a female patient suffering from sciatica, he first asked for a towel to cover the area between the patient’s legs before raising her leg to test the possibility of sciatic nerve entrapment. He clearly demonstrated sensitivity to the patient’s potential feeling of embarrassment caused by performing such a test while surrounded by students and residents. Through several of these “enlightening moments” at the bedside, he demonstrated his famous quote: “Students learn from observing how you do, rather than from what you say.”

Since then, I have continued my interest in bedside teaching while teaching at the University of Kansas Medical Center (1979-1998) and upon my return to Taiwan in 1998.

It is my personal conviction that bedside teaching should include not only medical knowledge and skills but also bedside manner, sympathetic listening and empathetic communication. Such teaching can serve as “booster shots” during clinical years to enhance the humanism that medical students learn in earlier years. For more than a decade, I have been conducting regular bedside teaching in three teaching hospitals for 5^th or 6^th year medical students at National Yang Ming Medical University, National Taiwan University, and National Cheng-Kung University during their clerkship rotating through neurology.

I would like to present the following two cases to illustrate how to enhance students’ sensitivity to the suffering of others (patients and their families), while also teaching neurological examination techniques, differential diagnoses, and management.

III. CASE 1: A PATIENT WITH MYASTHENIA GRAVIS WHO SUFFERS FROM DIPLOPIA

The diagnosis was delayed by his presenting chief complaints as “dizziness,” for which he visited several ENT doctors, until finally he was referred to neurologists. Students were puzzled by how the patient could “confuse” diplopia (“double vision”) with dizziness. I then demonstrated to students how to self-induce diplopia by stretching out their left arm, with index finger pointed to the sky, and then continue to stare at this finger while trying to apply pressure to their right eyeball with their right hand. This would artificially create different positions of the eyeballs (dysconjugation), resulting in problems with the fusion of two images projected from the retinae to the brain. This caused “double vision” and a dizzy feeling, which was exactly what happened to this patient. Students then appreciated what the patient was suffering and understood why the patient could perceive “double vision” as “dizziness.”

IV. CASE 2: A PATIENT AT THE END-STAGE OF AMYOTROPHIC LATERAL SCLEROSIS, A DEVASTATING MOTOR NEURON DISEASE THAT HAS NO EFFECTIVE TREATMENT

After the student presented the history of the patient, I reminded students to find out how we could help such a seemingly “medically helpless” patient. After observing severe bulbar symptoms and demonstrating the coexistence of upper and lower motor neuron signs at bedside, I thought it might be a good case to lead the patient into a discussion of serious issues related to end-of-life.

So I posed a question – “What do you worry about the most?” – trying to lead the patient into a discussion of whether he would consider accepting emergent intubation followed by long term ventilation when he developed difficulty with breathing. Unexpectedly, the patient responded, “What I worry about the most is my daughters’ education.” He then went on to share with us his story of how his lack of formal education due to poverty led him to the life-long misery of humiliation at work. Consequently, he has tried to save as much money as possible for his two daughters’ college education. Unfortunately, his financial status had been seriously compromised by his loss of job and increasing medical expenses since he became ill, at a time when his two daughters would soon graduate from high school.

After we left the patient and started discussing the patient’s neurological findings, one student reminded us that we had not discussed how to help this patient. She went on to share with us her thoughts: she would like to see the patient’s daughters, discuss with them whether they themselves were interested in going to college, and if so, she would urge them to speak to their father about their desire to work in the daytime and to attend college through evening school.

We were all impressed by this student’s thoughtful proposal, and I went on to praise her, saying that she had beautifully illustrated the truth of the following statement: “Although there is nothing more that can be done for the body, this does not mean that there is nothing more that can be done for the sick person” (Cassell, 2004).

V. GENERAL DISCUSSION OF HOW I CONDUCT BEDSIDE TEACHING

At the end of my bedside teaching, I usually ask students to share what they have learned. Students tend to recall cognitive learning, i.e. medical knowledge of diagnosis and treatment as well as clinical skills in neurological exam. Then under prompting, they begin to share their observations of behavioral/affective aspects and express their empathy towards the suffering of patients and their families. Some of them voice their appreciation for bedside manner and communication skills demonstrated by the medical team. At the end, I have consistently tried to raise their sensitivity and draw attention to the patient’s suffering. Lately, I like to share with students the joy of reading Dr. Charon’s succinct article, “To See the Suffering,” in which she writes, “To see the suffering might be what the humanities in medicine are for, and that those who become capable of seeing the suffering around them in medical practice both experience the cost of countenancing the full burden of illness and death and, simultaneously, comprehend with clarity the worth of this thing, this life.” (Charon, 2017)

 VI. MY PERSONAL PLEA FOR THE INTEGRATION OF CLINICAL MEDICINE AND HUMANITIES IN MEDICAL EDUCATION PROGRAM

Attention to humanistic issues at the bedside demonstrates to students the relevance and application of humanities in individual cases and leads to a deeper appreciation of what they have learned about medical humanities during their pre-med years. Consequently, such bedside teaching can serve as “booster shots” to rekindle students’ interest in the humanistic aspects of patient care. However, it is difficult to expect lasting effects on the attitudes and behaviors of medical trainees unless such teaching can be frequently and widely practiced throughout clinical rotations.

Therefore, I would like to recommend that more attending physicians in teaching hospitals should be encouraged to teach humanism at the bedside. Medical schools should set a high priority for the clinical faculty to help students enhance their sensitivity “to see the suffering” and develop empathy towards patients. If possible, such efforts should be incorporated into faculty development programs for clinical teachers from all clinical departments in teaching hospitals.  

Note on Contributor

Chi-Wan Lai, M.D. is the chair professor of medical education, attending physician in the Division of Neurology, Koo Foundation　Sun Yat-Sen Cancer Center, Taipei, Taiwan.

Funding

The author declares no funding is involved for this paper. 

Declaration of Interest

The author declares no conflicts of interest.

References

Cassell, E. J. (2004). The nature of suffering and the goals of medicine (2nd ed., p. 118). United Kingdom: Oxford University Press.

Charon, R. (2017). To see the suffering. Academic Medicine, 92(12), 1668-1670. https://doi.org/10.1097/ACM.0000000000001989

Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., … Scheffer C. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine, 86(8), 996-1009. https://doi.org/10.1097/ACM.0b013e318221e615

Plant, J., Barone, M. A., Serwint, J. R., & Butani, L. (2015). Taking humanism back to the bedside. Pediatrics, 136(5), 828-830. https://doi.org/10.1542/peds.2015-3042

Swartz, M. H. (2014). Textbook of physical diagnosis: History and Examination (7th ed., p. 564). Philadelphia, PA: Elsevier.

*Lai Chi-Wan
125 Lih-Der Road,
Pei-Tou District, Taipei, Taiwan
Telephone: +886 2 2897-0011
Email address: chiwanlai@gmail.com

Published online: 3 January, TAPS 2017, 2(1), 29-30
DOI: https://doi.org/10.29060/TAPS.2017-2-1/PV1027

Niraj Mohan & Yi Yan Chia

Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. INTRODUCTION

Surgery is an apprenticeship – an art to be learned by the operating table from our mentors and a skill to be honed through years of training. This article is a discussion of the significance of good role models in surgical education with personal examples given from our fresh experiences with the intricacies of surgery during our undergraduate medical education years.

II. PERSONAL VIEW

Many papers have explored the recent decline in the number of surgical residency applicants, and a large majority have attributed a lack of role models in surgery to be one of the key factors responsible for this decline (Maker et al., 2004). The history of surgery is filled with horror stories of raging and difficult surgeons. A recent study done on Korean surgeons confirmed that the much higher number of hours spent at work by surgeons is an important contributor of occupational stress and burnout (Kang et al., 2015). Similarly, in the United States, burnout and poor psychological well-being are common amongst surgeons and can negatively affect work performance, job satisfaction, career longevity and even the risk of suicide (Shanafelt et al.., 2012). We therefore qualify that surgery is a very stressful career with long working hours that could deprive a person of sleep and social life, hence logically speaking, even someone who is good-natured can snap in the heat of the stress. However, a good mentor-mentee relationship within the surgical discipline can translate into higher job satisfaction, and one is motivated to persevere on in spite of the high stress levels (Sinclair et al., 2014).

Good role models inspire and lead by example in their daily work. The importance of good role models in the surgical discipline is particularly important in view of high occupational stress levels. In spite of this tremendous occupational stress levels, we stood witness to many examples of surgeons who are willing to mentor their juniors, be it medical students, surgical residents or their fellow nurses: A surgeon who was post-call kindly took time off his busy schedule to provide an extra tutorial for his medical students out of goodwill as this tutorial was not counted as part of his teaching schedule. This same surgeon, sat his jaded residents down to provide them with sound advice on how to adapt to surgical residency life. Another surgeon calmly managed a scrub nurse who was new to work, and gave her a small tutorial on how to perform her job well instead of being displeased by her unfamiliarity with the surgical setup, and hence the multiple mistakes she made when asked to hand over certain surgical equipment at the operating table. A third surgeon took time to visit his surgical oncological patients outside of his working hours, just to walk the journey in battling a terminal illness with them.

The list goes on and on, but one mentor of ours probably summarized it best for us, “I often think about whether or not to quit surgery. Missing out on the birth of my brother’s daughter… not being able to attend many of the social invitations from my friends… slogging away whilst my friends of the same age were working much less hours yet earning much more. However, a large part of why I stayed on could be attributed to having good mentors. Mentors who are willing to let you do all the colonoscopies, even though they could probably do a faster job and go back home at an earlier time. Mentors who are willing to go the extra mile to make you feel appreciated for the amount of effort you put into your work… And because they did that for me, I pay it forward to my juniors.”

Teaching is a skill that a good role model in the surgical discipline should have. We were privileged to be under the tutelage of several surgeons who were awe-inspiring teachers. The first heart surgery we saw was by Dr. C for the repair of an atrial septal defect during an overseas clinical attachment to a tertiary hospital in Bangalore, India. Witnessing our first live beating heart, of a 10-year-old boy, was, by itself, a magical experience. To add to that, Dr. C, took time to explain the procedure and break down the intricacies to a simple enough form for us to comprehend.

If cardiac surgery is bold and daring, neurosurgery is delicate and intricate – that is what we have to say of the first neurosurgery we watched with Dr. K as the main operating surgeon in the same overseas clinical attachment that we were involved in. The neurosurgery involved a removal of a glioma (a type of brain tumour) from an elderly man. Our previous encounters with living brains were purely through the eyes of Derek Shepherd (a renowned fictional neurosurgeon in Grey’s Anatomy) and through the eyes of Cheung Yat Kin (a Hong Kong neurosurgeon in the Hong Kong television drama series – On Call 36 Hours). However, nothing could beat personally witnessing a live neurosurgery. Seeing the neurosurgeons expose the brain, the cerebral vessels, the meninges – the dura mater, arachnoid mater and pia mater – was truly awe-inspiring. The screwing back of the pieces of the skull created a beautiful anatomical jigsaw puzzle, which was then overlapped by the patient’s scalp.

A gentle yet firm mentor and a man of few words, who goes his way out in small and big ways to make us feel comfortable with him and his colleagues – that’s Dr. K. The neurosurgery team consisted of very approachable doctors who did not mind going back to the basics of neurosurgery to make us understand better and see how these fundamental building blocks of neurology and anatomy of the brain build a castle of applied neurosurgery.

Passionate about neurosurgery research, Dr. K’s eyes gleamed with excitement as he was sharing about new frontiers in research that he was engaging in, involving the use of advanced brain mapping to provide sensory input to arm prostheses to mimic a real-life arm. His passion rubbed off on us, allowing us to explore and read up on similar upcoming frontiers in Neurosurgery.

On a parallel note, the ward experience was equally enriching and heart-warming. While the both of us could not speak Hindi or the local language, we could tell from the patients’ facial expressions and gestures that the patients were very grateful towards the doctors and there was a genuine bond and relationship between the doctors and the patients. On a clinical front, there were plenty of opportunities for us to hone our clinical skills and it was indeed enjoyable interacting with all the patients.

Back at home, a study conducted in Singapore (Ibrahim et al., 2008) aimed at reviewing the local general surgical training programme in terms of patient safety and the performance of their trainee surgeon during the training and beyond found that there was no significant difference between consultant surgeons, trainee surgeons and newly trained surgeons in terms of operative complications, and length of hospital stay. This is largely, in part, due to the supervision of trainee surgeons and newly trained surgeons by consultant surgeons. During our surgical posting, we witnessed several such instances of apprenticeship by different surgeons across all sub-specialties. One such instance would be the unwavering guidance given by a senior consultant, Dr. T to his first-year surgical resident intra-operatively for creating flaps to gain access to the thyroid gland in a total thyroidectomy. There was a mixed thrill of excitement and trepidation as the first-year surgical resident dissected across the subplatysmal plane. Next to the first-year surgical resident, Dr. T’s eyes were fixated on the operating table, intently observing the surgical resident’s each and every surgical move, and stating clear instructions for his mentee to follow. Many such instances reassure us, young medical students, that in one or two years’ time, when we ourselves are in the same shoes as those of that of the first-year surgical resident, we would be able to also tap upon this apprenticeship, and learn our art and skills of surgery as well.

Whilst coming to the end of medical school, we are actually at the start of our journey to become a good clinician and a good teacher. All these experiences have not only piqued our interest in exploring Surgery as a residency option, but also to remember and keep close to our hearts, the value of being a lifelong teacher.

Notes on Contributors

Both authors are final year medical students from Yong Loo Lin School of Medicine, National University of Singapore.

Declaration of Interest

All the authors declared no competing interests.

References

Ibrahim, S, Tay, KH, Lim, SH, Ravintharan, T and Tan, NC (2008). Analysis of a structured training programme in laparoscopic cholecystectomy. Langenbeck’s Archives of Surgery, 393, 943–948.

Kang, SH, Boo, YJ, Lee, JS, Han, HJ, Jung, CW and Kim, CS (2015). High occupational stress and low career satisfaction of Korean surgeons. Journal of Korean Medical Science, 30, 133.

Maker, VK, Curtis, KD and Donnelly, MB (2004). Are you a surgical role model? Current Surgery, 61, 111–115.

Shanafelt, TD, Oreskovich, MR and Dyrbye, LN (2012). Avoiding burnout: The personal health habits and wellness practices of US surgeons. Journal of Vascular Surgery, 56, 875–876.

Sinclair, P, Fitzgerald, JEF, Hornby, ST and Shalhoub, J (2014). Mentorship in surgical training: Current status and A needs assessment for future Mentoring programs in surgery, World Journal of Surgery, 39, 303–313.

Published online: 5 September, TAPS 2017, 2(3), 26-27
DOI: https://doi.org/10.29060/TAPS.2017-2-3/PV1035

Gabriel Hong Zhe Wong¹, Philip Lin Kiat Yap² & Lawrence Wei Meng Tan²

¹Yong Loo Lin School of Medicine, National University of Singapore, Singapore;  ²Department of Geriatric Medicine, Khoo Teck Puat Hospital, Singapore

‘凡为医之道，必先正己，然后正人—-《医工论》

“First cultivate yourself; then cure others”.

Medical education strives to nurture ethical, caring doctors. Given the increasing commercialisation of medical practice, there is a need to include a discussion of ethical pricing in the medical curriculum. Ethical pricing refers to pricing that is both reasonable to the patient and the physician, ensuring that the patient is not used as a means to an end – the physician’s profit – and the fee is commensurate with the physician’s service. We believe the Confucian ethical paradigm, steeped in virtue ethics, can help guide such an educational objective. Confucian ethics offers a unique insight into Singapore’s approach towards medical pricing, perhaps best illustrated by the Singapore Medical Council’s (SMC) judgement on Dr Susan Lim. This can serve to guide and edify future medical practitioners.

While it may be challenging for students who have yet to commence medical practice to appreciate the nuances in medical pricing, incorporating the dialectics of pricing into an existing undergraduate curriculum in medical ethics stresses its importance and can help students better tackle the challenges of intuitive reasoning and ethical decision making in a dynamic real world environment. Some may also note that medical students, after they transition to junior doctors, have little say in the pricing decisions of their institutions. This may be the case even amongst many senior consultants in public and private hospitals. However, there is value in having students consider these issues, to foster greater empathy for the financial considerations of their patients and the challenges of ensuring viability of a medical practice, and in the hope that some can become advocates of ethical pricing within medical associations and in policy-making.

In 2011, Dr Lim, was convicted of overcharging by the SMC and suspended from practice. She had charged Bruneian royalty more than S$20 million for end-of-life care. In arriving at the judgement, SMC determined that there was an “ethical limit” to medical pricing (Singapore Medical Council, 2012) that if transgressed, could bring legal repercussions.

It also ruled “affluence” to be a non-factor in determining price, arguing that wealthy patients should be treated equally to poor ones, although doctors are encouraged to heavily discount the “indigent’s” treatment (Singapore Medical Council, 2012). Western jurisprudence raises concern over physicians’ liberty to freely price based on demand-and-supply, especially since the limit will be determined by “peers” in the profession (Singapore Medical Council, 2012), potentially introducing subjectivity.

There is no denying a wealthy patient’s right-to-health even as the doctor charges high prices. An injured sports personality of celebrity status, for example, saves millions in income and endorsements if the surgeon’s skills can help him achieve a speedy recovery. Since there is no discretionary exploitation occurring, should not the surgeon gain a share commensurate with his efforts?

The “unstated” ethical limit could be better understood through Confucian ethics, a dominant philosophy in Singapore. Confucianism practices a more intuitive, rather than critical, level of ethical reasoning which emphasises humanness. Liberties can only be exercised through participation within a community (Tsai, 2001) and with an emphasis on rites or customs, or “Li” 礼 which may not need to be codified (Wang & Solum, 2012). Therefore, the physician’s behaviour should be guided by the norms and prevailing practice of his fellow practitioners, hence allowing for a dynamic, evolving ethical price limit. Such a limit is governed by ethical and social considerations, unlike the amoral “invisible hand” in the free market.

Additionally, Confucian virtue ethics embraces the nobleman concept, which emphasises the importance of self-regulation. The noble “bears the suffering of patients in mind, not his own material interests” (Guo, 1995). In doing so, he demonstrates the principle of “Ren” 仁 that can transcend “contractual relations” (Low, 2011). Confucius stressed that economic agents must abandon selfish desires in transactions. From this perspective, if a physician seeks personal gain in pricing decisions, he transgresses the ethical limit.

Moreover, Confucianism espouses the principle of “Yi” 义 or righteousness. In the words of ethicist Chen Shih-Kung, it is based on “the idea of treating high or low, rich or poor equally” (Tsai, 1999).  Such a principle forbids the discrimination of individuals, including on the basis of wealth. This dovetails with the SMC’s (2012) stand that “we do not, however, accept that the affluence of the patient is an objective criterion which can legitimately be taken into account in setting or assessing what is a fair and reasonable fee” (p. 41) .

However, such a philosophy does not preclude physicians subsidising the care of patients who are unable to afford their fees. As Chen wrote, “Medicine should be given free to the poor. Extra financial help should be extended to the destitute patients if possible. Without food, medicine alone cannot relieve the distress of a patient” (Tsai, 1999).  Such a view is echoed by the SMC (2012) which deemed it morally exemplary to charge “an indigent patient a fee which is less than a fair and reasonable fee, or even to waive a fee, simply because the patient is indigent” (p. 41).

From a Confucian viewpoint, a more appropriate pricing yardstick would be the physician charging a price he himself would be willing to pay if he were in the patient’s position. This would come naturally to someone who practices deep self-cultivation such that he naturally embodies the Confucian virtue of Benevolence and Righteousness.

Medical profession’s nobleness cannot be over-emphasised. Confucian tenets can help in its expression.

Notes On Contributor

Gabriel Wong is a Year 2 Yong Loo Lin School of Medicine, NUS student. His interest in ethics and public policy was sparked 5 years ago when he published in the Lianhe Zaobao. Since then, he has published in several journals and hopes to one day shape Singapore’s healthcare future.

Philip Yap is a senior consultant geriatrician and palliative care physician in the Department of Geriatric Medicine and director of the geriatric centre in Khoo Teck Puat Hospital. He is also an Adjunct Associate Professor with the Yong Loo Lin School of Medicine, NUS.

Lawrence Tan is a senior consultant in the Department of Geriatric Medicine at Khoo Teck Puat Hospital. He has an interest in clinical ethics and is a member of the Clinical Ethics Committee in KTPH. He is also a Clinical Lecturer with the Yong Loo Lin School of Medicine, NUS.

Declaration of Interest

The authors declare no competing interests.

References

Guo, Z. (1995). Chinese Confucian culture and the medical ethical tradition. Journal of Medical Ethics, 21(4), 239-246.

Low, K. C. P. (2011). Confucius, the Value of Benevolence and What’s In It For Humanity? Conflict Resolution & Negotiation Journal, 1, 32-43.

Singapore Medical Council (2012). Singapore Medical Council Disciplinary Committee Inquiry for Dr Susan Lim Mey Lee Held on 21, 22, 23 May, 21 June and 17 July 2012. Singapore: Singapore Medical Association. Retrieved from http://goo.gl/m4x4aq

Tsai,  D. (1999). Ancient Chinese medical ethics and the four principles of biomedical ethics. Journal of Medical Ethics, 25(4), 315-321.

Wang, L. & Solum, L. B. (2012). Confucian Virtue Jurisprudence. In A. Amaya & H.  L. Ho (Eds.),  Law, Virtue and Justice. Oxford: Hart Publishing.

*Lawrence Wei Meng Tan
Khoo Teck Puat Hospital
90 Yishun Central
Singapore 768828
Tel: 66023041
Email: tan.lawrence.wm@alexandrahealth.com.sg

Published online: 2 May, TAPS 2018, 3(2), 58-60
DOI: https://doi.org/10.29060/TAPS.2018-3-2/PV1073

Poh Sun Goh

Yong Loo Lin school of Medicine, National University of Singapore, Singapore

Abstract

This article (and its accompanying and complementary presentation blog [https://telat14apmec.blogspot.sg/2017/01/elearning-in-medical-education-costs.html]) expands on ideas presented and elaborated on during the pre-conference workshop (https://telat14apmec.blogspot.sg/2016/09/essential-skills-in-elearning-pre.html), and main conference symposium (https://telat14apmec.blogspot.sg/2016/09/educational-technologies-propaganda-or.html) on this topic at the 14th APMEC. It will specifically address the issue of the costs involved, and value add of eLearning. It is presented in two sections, 1) as a series of short conversational style quotes intended to make a case for the use (or not) of eLearning / Technology enhanced learning, which were recently shared in the preamble to a more formal presentation on this topic; and 2) as a single paragraph compact article, augmented by internal keyword links to additional resources, links to the original workshop and symposium presentation blogs, an audio podcast (https://www.dropbox.com/s/7ltmt6z5unh6r6j/TeLforTAPS.m4a?dl=0), video (example1) (https://www.dropbox.com/s/igvpiya9j26kldg/TeLvid1TAPS.mov?dl=0) or video (example 1, embedded version below) demonstration, and interactive online bulletin (https://padlet.com/dnrgohps/practicalTipsToUseTeL) board (most updated versions of these media, and multimedia links will be on the blog).

The following section was first shared by Goh Poh Sun at 14^th APMEC 2017 with participants; and Education team at NUS Dentistry on 3^rd March 2017. The link can be found at https://telat14apmec.blogspot.sg/2017/01/elearning-in-medical-education-costs.html.

I. WHY USE TECHNOLOGY TO ENHANCE LEARNING (TeL)

eLearning, or Technology enhanced learning (learning enhanced  by use of the web/online through mobile devices, accessing digital content, and promoting learning activities and interactive learning through software and Apps), like any teaching aid or tool, need not be used if all the optimal conditions for teaching and learning exists in a traditional, bricks and mortar classroom, and there is no need to extend the educational reach of the teacher, or interaction with the student, beyond a single classroom encounter – with no necessity to engage and interact before or after class. (Goh, 2016c)

These “optimal conditions for traditional classroom learning” include having a skilled teacher available, fully present, rested, not interrupted (by phone calls – consultation requests or text – WhatsApp messages), in peak physical health (not unwell, jet lagged, sleep deprived); interacting with a class who are all present, fully engaged, in peak physical condition (not unwell, jet lagged, sleep deprived, not available to attend due to personal or other work commitments (running ward or clinic), not interrupted, not called away); and with students not required, and who do not require to pause a presentation-presentation or discussion narrative or process, reply to a point; and with all students able to ask questions as and when required by interrupting the presenter-teacher.

But if you want to extend and expand the “classroom”, and contact with students, before – during – and after class; to offer (all) students the ability of make points, and pose questions at the same time, and synchronously with the “live” presentation; to share and make accessible learning-educational content (for pre-reading) before class; and further reading-review after class; and for reference during class (recommended reading-resource material; not just material that students search for themselves) … if you (as the teacher), want to make the learning “recipe”, the learning and engagement process visible and transparent, not only for peer review-self review/reflection/evaluation for improvement, but also to allow students to revisit not only the content and interactive learning activities,  but also review and reflect on the learning and engagement process … and learn from this … then presenting directly and through an online platform (Goh, 2016h), with embedded engagement and interactive spaces and tools aids the digitally enabled teacher, and learner; not to replace traditional teaching and learning, in the physical classroom, with traditional methods and tools, but to enable, enhance, extend, expand teaching and learning opportunities and activities.

II. COSTS AND VALUE ADD

eLearning (https://www.instagram.com/p/BPOFFlnBxiw/?taken-by=gohpohsun&hl=en) or Technology enhanced learning leverages on the exponential increase in internet use (World Wide Anniversary Site, n.d.), connecting a local and global audience (Doug, 2011), increasingly through mobile technologies (Jillian, 2016), which put the internet into our pocket, or purse, giving access to information and learning opportunities on demand, at a time and place customised to an individual learners needs, yet scaling up easily to a whole class, cohort, or global interest group; assisting teachers to expand and extend learning and interactive, active discussion and engagement beyond the physical classroom, and increase contact time with learning material and activities, not only before, during and after scheduled “class-time”; to support ongoing learning (Goh, 2016e) and training from undergraduate, through postgraduate, to lifelong learning and continuing professional development; taking individual students from novices, through competency and proficiency, to expert level performance and mastery. The costs in time and effort are greatly reduced by a concerted ongoing effort to systematically create, collect and curate (with attribution) useful, usable and (high) quality educational and training material in digital form (content) which is indexed and hyperlinked accessible for immediate use (on demand, as required, within digital repositories) (Cook, 2014; Goh, 2016d); the use of low cost and free online tools and platforms, like Blogger (Goh, 2016h), Padlet (Goh & Sandars, 2016) and Instagram (Goh, 2016b), used exclusively for professional training purposes, following best practices, local and international guidelines and rules governing professionalism, protecting privacy, and respecting intellectual property. The focus is always on the quality, usability and usefulness of content (first), and our instructional purpose/learning objectives, our pedagogical intention, before searching for the lowest cost, easiest to use, and most accessible technological solution (T. Taveira-Gomes, P. Ferreira, I. Taveira-Gomes, Severo, & M. A. Ferreira, 2016), supported by best practices (empirical based and supported by the literature) in instructional design. These instructional practices may not use any technology (Goh, 2017) at all, or time tested “old-school” tech of microphones, paper and pen, chalk and a blackboard; or their online digital versions. TeL adds value by helping students, teachers, and administrators/funding agencies/parents “see what we actually teach with, and assess on” (Goh, 2016h), and makes the learning process and outcomes visible (Goh, 2016g) and increasingly measurable (Goh, 2016a), through data analysis and data analytics (see tip 10 on linked article [Rouhiainen, 2015]). Scholarly teaching, and educational scholarship can also be promoted through the use of online digital portfolios (Goh, 2016f), making our efforts as educators visible, accessible, and assessable; for colleagues and peers to critique, give feedback on, and add to our work. To sum up, technology can augment, amplify, enhance, expand and extend our educational efforts as teachers, making useful content accessible; and assisting active learning activities which when done online are easily visible, as well as accessible for more rapid feedback and review. Making regular, incremental efforts to add to our educational content, and refine our learning processes is not only low cost, but also cost effective, particularly when low cost or free online tools and platforms are used skilfully and thoughtfully by teachers with a strong foundation of pedagogical knowledge and understanding of the theory and practice of instructional design; working with an ever increasing repertoire and repository of reusable digital content and teaching plans; which are made easily available for a teacher,  as well as a larger teaching community to use through an indexed, peer and user reviewed, online digital repository; where not only highly viewed, rated, cited to, linked to, and downloaded material; but also all potential usable and useful material is visible, and accessible; to be used, reused, repurposed, and added to.

Notes on Contributors

Poh Sun Goh, MBBS, FRCR, FAMS, MHPE, FAMEE, is an Associate Professor and Senior Consultant Radiologist at the Yong Loo Lin School of Medicine, National University of Singapore, and National University Hospital, Singapore. He is an Associate Member of CenMED, NUS; a graduate of the Maastricht MHPE programme; current member of the AMEE eLearning committee/Technology enhanced learning committee; and a Fellow of AMEE.

Declaration of Interest

The author declare no competing interests.

References

Cook, D. A. (2014). The value of online learning and MRI: finding a niche for expensive technologies. Medical Teacher, 36(11), 965-72.
Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/250725 33. https:doi.org/10.3109/0142159X.2014.917284.

Doug, F. (2011, May 5). Re: Visualizing geographic data with the WebGL Globe.
Retrieved from http://googlecode.blogspot.sg/2011/05/visualizing-geographic-data-with-webgl.html”>http://googlecode.blogspot.sg/2011/05/visualizing-geographic-data-with-webgl.html.

Jilllian, D. (2016, June 1). Re: Mary Meeker’s stunning annual presentation on the state of the web.
Retrieved from http://www.businessinsider.com/mary-meeker-2016-state-of-the-web-presentation-2016-6/?IR=T#CFJpu36krODtrEYC.97.

Goh, P. S. (2016a). A proposal for a grading and ranking method as the first step toward developing a scoring system to measure the value and impact of viewership of online material in medical education – going beyond “clicks” and views toward learning. Amee MedEdPublish, 5 (3), 62. https://doi.org/10.15694/mep.2016.000148.

Goh, P. S. (2016b). Doctor, Educator, Tech Geek. Retrieved from https://www.instagram.com/p/BPOFFlnBxiw/?taken-by=gohpohs un&hl=en.

Goh, P. S. (2016c). eLearning or technology enhanced learning in medical education-Hope, not hype. Medical Teacher; 38(9), 957-8. https://doi.org/10.3109/0142159X.2016.1147538.

Goh, P. S. (2016d, July 2). Everything I have learnt about eLearning. Retrieved from https://www.slideshare.net/dnrgohps/everything-i-have-learnt-about-elearning.

Goh, P. S. (2016e, October 2). Flipped classroom workplace learning educational technology pedagogy. Retrieved from https://www.slideshare.net/dnrgohps/flipped-classroom-workplace-learning-educational-technology-pedagogy.

Goh, P. S. (2016f, December 23). Medical Education and eLearning Portfolio.
Retrieved from https://medicaleducationelearning.blogspot.sg/2016/12/my-elearning-journey.html.

Goh, P. S. (2016g). The value and impact of eLearning or Technology enhanced learning from one perspective of a Digital Scholar. Amee MedEdPublish, 5(3), 31. https://doi.org/10.15694/mep.2016.000117.

Goh, P. S. (2016h). Using a blog as an integrated eLearning tool and platform. Medical Teacher, 38(6), 628-9. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26558420.

Goh, P. S. (2017, January 14). Learning is objective. Retrieved from https://www.instagram.com/p/BPOF-mTByKL/?hl=en.

Goh, P. S., & Sandars, J. (2016). An innovative approach to digitally flip the classroom by using an online “graffiti wall” with a blog. Medical Teacher, 38(8), 858. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27414992. https://doi.org/10.1080/0142159X.2016.1204433.

Rouhiainen, L. (2015). 12 E-Learning and Online Learning Best Practices. Retrieved from http://www.lasserouhiainen.com/12-e-learning-and-best-practices/.

Taveira-Gomes, T., Ferreira, P., Taveira-Gomes, I., Severo, M., & Ferreira, M. A. (2016). What Are We Looking for in Computer-Based Learning Interventions in Medical Education? A Systematic Review. Journal of Medical Internet Research, 18(8), e204. http://doi.org/10.2196/jmir.5461.

World Wide Web Anniversary Site (n.d.). Internet live stats. Retrieved from http://www.internetlivestats.com/internet-users/.

*Poh Sun Goh
Department of Diagnostic Radiology
National University Hospital
5 Lower Kent Ridge Road
Singapore 119074
Tel: (65) 67795555
Email: dnrgohps@nus.edu.sg

Published online: 2 May, TAPS 2018, 3(2), 55-57
DOI: https://doi.org/10.29060/TAPS.2018-3-2/PV1060

Sethuraman K. Raman

Faculty of Medicine, Sri Balaji Vidyapeeth, India

I. INTRODUCTION

A. Why this is an issue of global relevance

India is the world’s largest exporter of doctors and healthcare workforce to other nations. More than 70,000 medical graduates from India (nearly 10% of the qualified doctors in India) are in the USA, UK, Europe, and the other nations. Therefore, the quality of medical education and the competence level of medical professionals from India acquire global relevance. Over the years, several critiques have been published on Indian Medical Education (Solanki & Kashyap, 2014).

II. PERSONAL VIEW

A. Strength of Indian Medical Education: Quantity

“The best medical schools in India are absolutely world class,” said David Gordon, president of the World Federation for Medical Education.

In terms of numbers, there has been a great upward surge in the recent years. In 2016, there were around 57,000 medical seats in India, of which 28,000 seats were in the public sector and 29,000 in the private sector. An addition of 10,000 MBBS seats have been announced for the current year (2017-18) to be shared among 58 medical colleges run by the Government, which would make it as 67,000 MBBS seats per annum. As on 12^th April 2017, there were 460 medical colleges with a total of nearly 64,000 seats for MBBS.  The postgraduate seats have been increased by 4,000 for 2017-18 giving a total of over 35,000 PG seats for this academic year.

B. Weakness: Variable Quality

While the top 25% to 30% of the 460 colleges offer high quality medical education (adopt the current best practices in designing, maintaining, and enhancing medical education programmes), the others are mediocre or below par. In mediocre institutions, it is left to the motivation level of the individual student to strive and acquire the basic competencies expected in a primary care physician. That many medical doctors are not more competent than untrained ‘quacks’ was revealed by a study (Das et al., 2012) funded by the Bill & Melinda Gates Foundation: this study compared the doctors holding medical degrees with the untrained practitioners and found no differences in the likelihood of either group of providers diagnosing correctly or providing the correct treatment. The study concluded that in India, formal training in Medicine did not guarantee quality practice.

Institutions below par try to cover their deficiencies by the use of ingenious street-smart methods. The Medical Council of India (MCI) is well aware of such behaviour and the Council recently barred 32 colleges across the country. A recent news report reconstructs how one of those marshalled doctors on hire, fake patients and life-saving equipment on rent for inspection day to cover up their deficiencies (Krishnan, 2017). Even some of the “Institutions of National Importance” are not immune from such deficiencies: the first cohort of medical students of one of the newly set up AIIMS would reportedly graduate without practical skills due to several deficiencies including the absence of functioning operation theatres. As these are Government run public institutions, their violation of the norms is either condoned or goes unchecked.

The sad state of affairs persists because the “pliable Universities and Councils” are made to bend rules and violate standards of quality in order to accelerate the business of medical education; this is pushed through by politicians for political advantage or by private players for profit. In a four-month investigation reported in 2015, Reuters has documented the full extent of the fraud in India’s porous system of medical-education (MacAskill, Stecklow, & Miglani, 2015).

A Parliamentary committee report has recently said this: Indian Medical Council (IMC) Act 1956 provided India the initial impetus for the growth of medical education; sadly, the Council has not kept pace with time. Various cracks have appeared in its structure and functions that have had deleterious effects on medical education and by logical extension, the delivery of quality healthcare. Moreover, India is perhaps the only country with two parallel systems of Post-Graduate Certification by MCI and National Board of Examinations (NBE) respectively, which needs to be rectified (NITI Aayog, 2016).

C. Weakness – Scientific Research:

A recent review of the research output during 2005-2014 reported that only 25 academic medical institutions produced >100 papers a year, contributing around 40% of India’s research output in medical sciences. Around 330 academic medical institutions – belonging to MCI and Diplomate in National Board streams – did not publish a single paper during this 10-year period. Two states with the most number of private academic medical institutions, viz., Karnataka and Kerala, fared the worst with zero publication.

D. Challenges – Globalization:

Globalization of medical education has created a huge demand for English speaking medical educators, especially in China, East Europe, Arab nations and erstwhile Soviet Republic. Several hundreds of qualified and experienced medical teachers have left India on teaching assignments resulting in severe shortages in many departments of medical sciences.

Similarly, to escape from the prohibitive cost of higher education in its private sector, India has become a net consumer of overseas education, spending nearly $3 billion a year to study abroad. In 2008, industry estimates had announced that annually, 150,000 students went for studies overseas. A significant proportion of them went to study Medicine. There is a downward trend in spending for overseas education and it has dropped by 20% to $2 billion in 2015-16 from $2.5 billion in the previous year.

E. Opportunities

Global funding patterns clearly show that medical education still remains a state dominated sector run with public funds. In countries belonging to the Organization for Economic Cooperation and Development (OECD) such as Denmark and Holland, public funding provides 98% of health resources in this sector. The figure is nearly 90% for Canada and as high as 78% even in the US.

Globalization demands a paradigm shift in the regulation of medical education in India. To meet the current demands of globalization, the Indian government must spend more on medical education, increase student access, and permit greater autonomy with accountability to its universities. More funding combined with greater flexibility and autonomy, would strengthen the research capacity. India’s rigid regulation of all aspects of medical education blocks the intellectual growth of its academia, and diminishes its ability to attract global talent to enhance the quality of medical education to world standards.

Starting from the academic year 2016, the Supreme Court of India has ordered that all the medical and dental colleges admit students based of the individual rank obtained by each student in the ‘National Entrance cum Eligibility Test’ (the NEET exam). NEET is a single entrance examination in the country for providing admissions to medical (MBBS) and Dental (BDS) seats across all medical colleges/universities in the country. A total of 731,223 appeared in the NEET-UG-2016; 409,477 candidates qualified, out of which the top ranked 28,000 were eligible to enter the Government colleges, while the remainder could try to  enter any of the private colleges.

The Parliamentary Standing Committee’s Report-92 of 2016 has recommended the formation of a National Medical Commission (NMC) through a new Act to replace the IMC Act. The NMC will have four verticals, viz., (i) UG Board of Medical Education and Training, (ii) PG Board of Medical Education and Training (iii) National Assessment and Accreditation Board and (iv) National Board for Medical Registration (NITI Aayog, 2016).

The committee has also recommended common entrance and exit examinations for both undergraduate and post-graduate medical education. It has recommended restructuring of the postgraduate medical education under a single control by merging the best elements of both the systems, viz., the Medical Council of India and the National Board of Examinations (NITI Aayog, 2016).

Meanwhile, MCI has released its vision for value added MBBS course. Ten new teaching-learning components proposed in its Vision-2015 document are:

1) A preparatory Foundation course;
2) Curricular integration, both Horizontal and Vertical;
3) Early Clinical Exposure;
4) Student-Doctor mode of hands-on Clinical Training;
5) Electives and self-directed learning;
6) Competency-based Training with certified skills acquisition;
7) Secondary Hospital Exposure;
8) Adoption of Contemporary Education Technologies;
9) Integration of principles of Family Medicine;
10) Integration of ethics and professional values in all phases of the course.

F. Summing up: Bright Future Beckons

The current initiatives undertaken by the government and the regulatory agencies augur well for the betterment of medical education in the foreseeable future in India. Concerned professionals and informed citizens would endorse the Parliamentary Standing Committee’s strong plea to the Government of India to quickly usher in a radical reform of medical education with focus on national relevance so as to cleanse the present ills and defects and to elevate Indian medical education to align with the current global pedagogic practices (NITI Aayog, 2016).

Note on Contributors

Professor K.R. Sethuraman is currently the Vice-Chancellor of Sri Balaji Vidyapeeth, a deemed-to-be-University at Puducherry, India, and formerly the Dean of Medicine and Deputy VC (Academic & International Affairs) of AIMST University in Malaysia.

Acknowledgements

The permission granted by Shri M.K. Rajagopalan, Honorable Chancellor of Sri Balaji Vidyapeeth to publish this article is gratefully acknowledged.

Declaration of Interest

The author has no conflict of interest to declare.

References

Das, J., Holla, A., Das, V., Mohanan, M., Tabak, D., & Chan, B. (2012). In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health Affairs, 31(12), 2774–2784. https://doi.org/10.1377/hlthaff.2011.1356.

MacAskill, A., Stecklow, S., & Miglani, S. (2015, June 17). Why India’s medical schools are plagued with fraud. Retrieved from http://www.reuters.com/article/us-india-medicine-education-specialrepor-idUSKBN0OW1NM20150617.

Medical Council of India. (2011, March). Vision 2015.
Retrieved from https://old.mciindia.org/tools/announcement/MCI_booklet.pdf

NITI Aayog, Government of India. (2016, August 7).  A Preliminary Report of the Committee on the Reform of the Indian Medical Council Act, 1956.
Retrieved from http://niti.gov.in/writereaddata/files/document_publication/MCI%20Report%20.pdf.

Krishnan, V. (2017, February 25). Betraying the oath. Retrieved from http://www.thehindu.com/sci-tech/health/betraying-the-oath/article17362851.ece.

*Prof Sethuraman K. R.
Pondicherry-607403, India
Tel: (+91) 4132611802
Email: krs@sbvu.ac.in

Published online: 4 September, TAPS 2018, 3(3), 46-48
DOI: https://doi.org/10.29060/TAPS.2018-3-3/PV2000

Seow Chong Lee & Foong May Yeong

Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

I. INTRODUCTION

One of the biggest challenges at engaging undergraduates effectively in Biology modules is large class size (Wood, 2009). Typically, the class size of an undergraduate Cell Biology module in our institution ranges from 200 to 300 students. Instructors of large class modules traditionally teach didactically by simply disseminating facts, which become outdated quickly in this growing field of science. Furthermore, using didactic instruction, it is difficult to help students develop skills such as critical-thinking expected of our university graduates.

From the students’ perspective, unless the contents and/or teaching methodology interest and engage them, there is little motivation to go beyond superficial learning (Finn & Zimmer, 2012). However, once engaged, students might develop the intrinsic motivation to master the essential contents and skills required for deeper understanding. This might be relevant for their further progression in science or even in their personal life after they graduate from University.

Among different teaching methodologies used to engage students, active-learning during classes is increasingly being used (Wood, 2009). Active-learning can be conceptualized using the idea of generative-learning (Osborne & Wittrock, 1983), in which learning activities are designed to promote cognitive rather than behavioural processes. Such learning activities require students to link together pieces of knowledge acquired to create meaning in a given context. At an advanced level, students should be able to apply their knowledge to different contexts and think critically.

One of us has incorporated active-learning in teaching, through in-class quizzes using online classroom response systems (Yeong, 2015). While the quizzes generally increased class participation, it was difficult to encourage student engagement with the subject once classes are over. Hence, in the past semester, we designed an online reading assignment to foster student engagement in an authentic manner outside classes.

To this end, research articles were used in assignments to support generative-learning outside class. These research articles provide opportunities for students to analyse and interpret data, as well as make connections between concepts taught in class and their application in research work. More importantly, the assignments were designed as group-based activities based on Vygotsky’s idea of zone of proximal development (Vygotsky, 1978) and peer learning. Here, we describe our experience and perspectives using an online, anchored-discussion assignment to foster student learning and engagement, as mediated by the Perusall platform (<https://app.perusall.com>).

II. METHODS

In the academic year 2016/2017 semester 2, research papers were uploaded onto Perusall for students in the module to read and make comments. There were no restrictions on the comments that students can make; students can ask questions, analyse data and critique the paper. The Perusall platform allows students to reply to each other’s comments and questions. The platform was programmed to score the best 12 comments each student made. Students’ comments were graded automatically by Perusall but checked manually by instructors.

Students were randomly assigned into groups of six, and had one week to read and comment on each paper. Each assignment made up 4% of students’ grades; two assignments were administered during the semester. The first article was on the interaction of a fungal pathogen with macrophages, while the second related defects in cell cycle regulation to cancer. These articles were linked to topics in taught in class, namely lysosomal function and cell cycle regulation respectively. After the reading and commenting assignment, students had to complete an open-book, in-class quiz per article.

III. STUDENT LEARNING OUTCOMES

The two assignments yielded a total of 3344 and 2913 comments from 245 students respectively. After the semester, we performed preliminary content analyses on a random selection of students’ comments. The comments varied in complexity and presentation. For instance, many comments were statements that defined terms, or stated the purpose of experimental techniques that were unfamiliar to the students. Several comments of higher complexity, such as those that explained and interpreted data were also noted. In others, students cited other research papers to support their comments. We further found students using diagrams and concept maps to link and illustrate their ideas.

We observed interactions among students in which exchanges revolved around correcting and building of concepts proposed by the earlier contributors. These conversations usually started with a question, and students with different levels of knowledge on subject provided inputs regardless of the depth of understanding on the subject matter. These collaborative efforts often resulted in better understanding for some students who posed questions and a more rounded perspective on the question at hand for others.

The interactions among students at times extended beyond the context of the articles. We noted exchanges among students that started with questions about ambiguities in the data, and ended with the acknowledgement of subjectivity of interpretation of data. We also read questions about the functions of biological molecules that triggered discussions on general concepts of biology, ranging from the involvement of biological molecules in multiple pathways to applications of knowledge to drug designs. These observations suggest that the exposure to primary literature when coupled with discussions among students furthered their understanding to the nature of science and scientific research.

IV. PERSPECTIVES

The online assignments appeared to have engaged the students, as evident from the sheer number of comments received per research paper. It was gratifying to note that a number of the comments were high cognitive level comments where students demonstrated synthesis of knowledge. Furthermore, the level of engagement extended beyond the assigned research paper as students quoted other research papers to support their stand in the comments. The comments also made explicit some of their misconceptions to the instructors. This allowed the instructors an opportunity to correct the students, something not usually possible for didactic teaching in large-classes.

From our experience, some Asian students are shy to voice out their questions and opinions in class. In the online platform, students were not penalized by any comments made. Furthermore, the environment on the platform was overall rather friendly. These might have encouraged students to participate freely in the discussion without the fear of being embarrassed by their perceived “ignorance”. More importantly, by making comments even with their incomplete knowledge, students got to learn from constructive comments from their peers. This type of learning is not facilitated when a didactic approach of teaching is used, as facts are just delivered to the students through lectures, handouts and textbooks.

The assignment also provided the opportunity for knowledge building among students. For instance, students built up concepts by adding information onto earlier comments. Students’ comments were not restricted to the context of the paper, but extended to the nature of scientific research. This was similar to the scientific discourse that scientists engage in debates about ideas and approaches through publications and conferences. Such discourses widened students’ perspectives on the topic of interest as they gained better understanding of the article or topic discussed. Thus, authentic learning of science through collaborative learning and engagement in scientific debates can be supported in large classes by online platforms such as Perusall.

The use of a research article-anchored discussion-based assignment for a large class comes with some caveats. Firstly, we need to find suitable research articles that are suitable for the undergraduate students. Articles should contain sufficient content related to concepts taught in class, and the data should be interpretable by students without requiring specialized knowledge from a specific field. For this, sufficient time for preparation and planning of both the teaching and research article selection is important.

Secondly, though present, the total number of higher cognitive level comments was not very high. This could be improved by explaining to students the types of comments according to Bloom’s taxonomy (Wood, 2009) and encouraging students to go beyond providing definitions and focus on interpretation of data and synthesis of understanding. In addition, the duration of the assignment could be lengthened so students have sufficient time to provide more considered comments. The weightage of the assignment could be increased to reflect the emphasis of the skills students should develop and demonstrate for the assignment.

Thirdly, the number of comments for each research article was huge for a large class. The automated marking by Persuall while useful, appeared to be based on level of sentence complexity independently of context. While the instructors had read through individual comments to check the automatic grading, given the huge number of comments and time constraints, not all the misconceptions were addressed on time. This may be mitigated with the help from teaching support staff who can look through the students’ comments and compile the misconceptions. Alternatively, the support staff can comment directly in Perusall to correct misconceptions. The number of students per group could increase slightly so that there are potentially more students to support one another.

Overall, from our initial observations, the interactive format of the anchored-discussion assignment combined with the use of primary literature appeared to promote authentic scientific learning in a collaborative setting. As a tool, Persuall was a very good platform for such assignments to engaging students outside of class time. The impact of using online, collaborative reading assignments on student learning outcomes certainly warrants further exploration and in-depth analysis.

Notes On Contributor

Associate Professor Foong May Yeong conceptualised the assignment and taught the module as one of the instructors. Dr Seow Chong Lee helped with the design of the assignment. Both authors noted misconceptions, graded comments and performed the preliminary content analysis on a random selection of comments.

Acknowledgements

We are grateful to Eric Mazur and Brian Lukoff for the use of and support for Perusall. We also acknowledge Dr Jeya Kumar s/o Ramalingam for providing support to highlight misconceptions and grade comments at Perusall during the semester.

Declaration of Interest

All authors declare no potential conflicts of interest.

References

Finn, J. D., & Zimmer, K. S. (2012). Student engagement: What is it? Why does it matter? Handbook of research on student engagement (pp. 97-131). Boston, MA: Springer.

Osborne, R. J., & Wittrock, M. C. (1983). Learning science: A generative process. Science education, 67(4), 489-508.

Vygotsky, L. S. (1978). Mind in society: The development of higher mental process. Cambridge, MA: Harvard University Press.

Wood, W. B. (2009). Innovations in teaching undergraduate biology and why we need them. Annual Review of Cell and Developmental, 25, 93-112.

Yeong, F. M. (2015). Use of Constructed-Response Questions to Support Learning of Cell Biology during Lectures. Journal of microbiology & biology education, 16(1), 87.

*Foong May Yeong
Department of Biochemistry
Yong Loo Lin School of Medicine
National University of Singapore
MD4, 5 Science Drive 2
Singapore 117545
Tel: (65) 6516 8866
Email: bchyfm@nus.edu.sg

Published online: 4 September, TAPS 2018, 3(3), 43-45
DOI: https://doi.org/10.29060/TAPS.2018-3-3/PV1068

Wu Jiansheng

Clinical skills centre, West China School of Clinical Medicine, Sichuan University, China

I. GENERAL UNDERSTANDING THROUGH ACTIVE PARTICIPATION

As one of the first generation of Standardised Patients in China, perhaps Asia as well, I have been working in the clinical skills training centre in West China Medical School of Sichuan University for 25 years. I would like to share with you how I joined this little-known and somewhat mysterious field, participated in this form of teaching, and progressed from a normal SP to a SP trainer. It is noted that the Standardised Patient (SP) was first introduced by Howard Barrows in 1963 (Pan & Luo, 2017). In 1993, West China School of Clinical Medicine, Sichuan University was the first to do the training courses and trained the first group of SPs. In 2003, China Medical Boar (CMB) America organized a “Student Evaluation Plan Program”; 8 Chinese medical schools joined and imported the training programme to China.

In February 1992, I was taking a walk along the campus when I saw the notice for the recruitment of teaching instructors. It seemed like I was suited for the job, so I signed up after discussing with my wife. In April, I joined the West China Medical School which had started a training course lasting more than a month, with rigorous training and several rounds of examinations. Fortunately, I passed the examinations set by the school teachers, American experts and some SPs. The examinations presented as follow: first, senior medical students interviewed us, and we provided feedback accordingly. The assessment team members were observing, recording and evaluating the whole process. The reports of the SPs and the assessment team members were then analysed and compared (r>0.80) to determine whether the SPs were qualified and could give fair and standard evaluation. Finally, I had the honour of being selected as one of 39 (out of 93 candidates) SPs who passed the assessment. I accepted the job in June of the same year.

Through training, I have come to the conclusion that the SP is a simulated patient who can realistically portray the actual patient’s problems after special training. In the teaching process, the SP has three roles: to act as a patient, a “judge”, and to provide feedback and instruction. The SP teaching model focuses not only on the teaching process, but also emphasizes the students’ attitude toward the patient and the ability to care for and communicate with the patient. It is commonly used in the teaching, training and evaluation of medical students, and has now been applied in the evaluation of practising physicians.

The so-called “SP” mainly serves to ensure uniformity in the content and evaluation methods, standardisation of replies on the same questions posed to different medical students, and that the same “patient character” is presented to the medical students. As for clinical teaching, SPs have played a significant role in supporting the training of professional and high-quality medical talents through the enactment of the same scenario and having a standardized evaluation system. Although it accounts for only a small part of the entire clinical teaching, it is essential and helpful in training a medical student to become a qualified doctor. Whenever I see another batch of medical graduates become qualified doctors and they sincerely appreciate your assistance during their learning, I feel gratified and have a great sense of achievement from the bottom of my heart.

II. TOTAL DEVOTION

Based on this understanding and a high sense of responsibility for the work, I devote myself wholeheartedly to learning the SP methodology. I take every training seriously; listening attentively to each class, and making detailed notes. I also make notes of every teaching class for future use of statistical analysis. It allows me to improve my teaching ability by summing up and promptly correcting the problems found through teaching. In the beginning, I was assigned to the paediatric interrogation group, led by Professor Wan Xuehong of the West China School of medicine, who went to study about SP methodology in 1992. I was assigned to play the role of a “mentally retarded” child’s parent, which was really not easy for me, as parents with different backgrounds will react in totally different ways. In order to play different types of parents, I even went to a hospital to observe how children and parents behave. Combined with my own experience as a parent, I gradually become better at portraying the different roles. For example, as a parent of a child with fever, I displayed anxiety – looking panicked, speaking very fast and desperate to describe the child’s condition to the doctor. As for a case of hypophrenia, I appeared to be slightly haggard and rogue, displaying impatience and worry for the child’s disease, complete with eyes full of expectations.

In 1993, Professor Liu Wenxi personally trained and arranged for me to play a patient with “chest pain” This training was important because it was to become part of the multi-station test for medical graduates, which needed well trained SPs with strong ability to play the role as authentically as possible, and to evaluate effectively too. After successfully passing the training, I began to take on work as a SP in the examinations of medical graduates. Usually, we have to work around 12 hours and be subjected to some 36 medical students’ interrogation a day. Other than repeated expressions, moves, and questions, I also need to focus specially on the following aspects: the contents and skills of their questioning, their ability to show care for patients, and if they adhere to medical procedures. Only then can we give an accurate and fair evaluation based on their comprehensive performances. I feel really tired after a day’s work. But over time I began to acquire enough experience and a strong foundation to become a SP trainer. It is all worthwhile. I truly feel happy and proud that I can do something for the nation’s medical education.

III. ENHANCING UNDERSTANDING THROUGH LONG-TERM TEACHING PRACTICE

In the past 24 years, I have taken on the role of SP for many different medical conditions,  including: parent of a child with fever, “chest pain”, “abdominal pain”, “cough”, “asthma”, “haemoptysis”, “palpitations”, “Oliguria and oedema”, “array room speed”, and other adult diseases. All these experiences have deepened my understanding of the role of an SP. I can play an important role as a simulated patient, an assessor and an instructor. The ultimate purpose is to give prompt, accurate and fair feedback and evaluation to help medical students become professional clinical doctors.

Years of teaching practice have made me realize the profound meaning of a saying by Professor Paula L. Stillman (Dean of the Faculty of Medicine, University of Massachusetts) that “Every time you encounter a medical student, the most important thing is that you want to give him valuable feedback, and that he can leave your class with an unforgettable memory and brought back more than when he first came in”. (Professor P. L. Stillman, personal communication, May 28, 1992.)

IV. NOT ONLY MEDICAL SKILLS, BUT ALSO HUMANISTIC CARE

To a medical student, professional knowledge and clinical skills could be one of his wings, and the other wing is his humanistic care and communication skills. And only with two wings can he soar. Therefore, SP teaching is with significant meaning as we train our medical students to become professional doctors with strong caring ability. Medical students often say that real patients and SPs are very different. Many patients have refused to become a doctor’s “teaching material”, and many do not want to cooperate with medical students. But SPs can consistently and “accurately” portray a specific injury, illness and medical condition to many students. Indeed, the introduction and application of the SP teaching model is a good solution to help avoid the moral risks and disputes between doctors and patients.

V. BECOMING A SP TRAINER

Being involved in this extraordinary work not only enriched my life and enhanced my medical knowledge, it also allowed me to learn a lot from the hard-working, energetic young students. Being in the company of medical students also keeps my mind active and allows me to deeply understand that teaching and learning can complement each other.

The West China Institute of Clinical Medicine recommended me to participate in the training of SPs in 2006. Through these learning exchanges and trainings, I noted that many medical colleges realise the importance of SPs, but lack the relevant conditions, experience, and SP teaching staff. In order to better solve these “problems”, we should encourage experienced, and resource-based medical institutions to establish SP teacher training centres as soon as possible.

In 2017, I was appointed as an SP Expert by the China SP Practice Teaching Guidance Committee and have since been involved in the development of SP teaching materials. With great confidence and a strong belief in the SP methodology, I will continue to dedicate myself to my career as an SP trainer.

Notes On Contributor

Mr. Wu Jiansheng is currently the SP trainer of Clinical Skills Centre, West China School of Clinical Medicine, Sichuan University in China and the Expert member of China SP Practice Teaching Guidance Committee.

Acknowledgement

Chinese – English Translators:

Chaoyu Wang and Linda Liu

China SP Practice Teaching Guidance Committee, Beijing, China, 100010

Declaration of Interest

The author has no conflict of interest to declare.

References

Pan, H., & Luo, L. Z. (2017). Standardised Patient General Introduction and History. In Sheng, Y. & Pan, H. (Ed.). Biaozhunhua Bingren Peixun Shiyong Jiaocheng -Standardised Patient Training Applying Courses. Beijing, China: Science Press Co. Ltd.

*Wu Jiansheng
SP trainer from Clinical Skills Centre,
West China School of Clinical Medicine
Sichuan University
Chengdu, China, 610041
China SP Practice Teaching Guidance Committee,
Beijing, China, 100010

Published online: 2 January, TAPS 2019, 4(1), 62-64
DOI: https://doi.org/10.29060/TAPS.2019-4-1/PV1066

Simon Tso^1,2

¹Department of Dermatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom; ²Warwick Medical School, University of Warwick, Coventry, United Kingdom

I. GRADUATE-ENTRY MEDICINE DEGREE PROGRAMMES

Graduate-entry medicine degree programmes exist in many countries. In the UK, graduate-entry medicine degree programmes began in 2000 and accounted for approximately 10% of the annual intake into all undergraduate medicine academic programmes (Garrud, 2011). There had been relatively few studies exploring the impact of prior experience on graduate-entry medical students’ medical school journey. Rapport and colleagues (2009) reported prior work and life experience had a significant and positive impact on medical students’ degree programme experience. Their prior experiences had helped them understand complex concepts in professionalism, ethics and reflective learning, as well as how to manage patient encounters (Rapport et al., 2009). On the other hand, the authors noted the nature of medical students’ previous degree subjects had ‘virtually negligible effects’ on their current degree programme experience (Rapport et al., 2009). Gallagher and Hoare (2016) explored the transition experience of New Zealand medical students that were health professionals. The authors reported these medical students retained a number of generic core skills (e.g. patient communication, professionalism, teamwork, familiarity with the health care environment) from their previous health profession role and were able to apply these skills to their medicine degree programme (Gallagher and Hoare, 2016).

II. MY EXPERIENCE

I recently conducted an interview based study to explore the experience of twenty-one University of Warwick graduate-entry medicine degree programme students, which helped me understand the impact of medical students’ prior academic and professional experience on their medical school journey.

In my study, volunteers were asked to describe their academic and professional experience prior to their graduate-entry medicine degree programme. Audio recordings of their semi-structured interviews were transcribed verbatim. The transcripts were analysed using thematic analysis (Braun and Clarke, 2006).

The study findings showed all study participants had completed a university degree programme prior to admission into their graduate-entry medicine degree programme. Their highest tertiary qualifications were a bachelor’s degree (18 of 21; 85%), master’s degree (two of 21; 10%) or PhD (one of 21; 5%). The nature of their previous degree programme subject could be broadly divided into two groups. One group consisted of 18 of 21 (85%) medical students with a previous degree subject related to natural sciences (i.e. chemistry, biology, biochemistry, genetics and biomedical science) or health (i.e. pharmacology, radiography and clinical technology). Another group consisted of three of 21 (15%) medical students with a previous degree in other subjects (i.e. geography, engineering and information technology). Thirteen of 21 (62 per cent) medical students had prior full-time employment experience, of which 10 had worked in health related settings (i.e. worked as allied healthcare professionals or first responder in emergency rescue services) and 3 had worked in other settings (i.e. sports coaching, engineering and business consultancy). Eight of 21 (38 per cent) medical students did not have full time work experience prior to admission into their graduate-entry medicine degree programme. Analysis of transcripts from interviews revealed four broad themes.

1) Theme: Development of transferable generic skills

Medical students generally perceived their prior life experience and transferable skills set (such as team working, communication skills and time management skills) had increased their preparedness towards student life in a graduate-entry medicine degree programme.

2) Theme: Development of transferrable subject specific skills

Some medical students in possession of a university degree in a natural science or health subjects reported they were able to directly transfer or apply some of the concepts and knowledge they previously learnt into their graduate-entry medicine degree programme. Some medical students used to be health professionals with prior direct patient care experience and they were already able to perform clinical procedures that were directly relevant to the learning outcome of their medical school curriculum.

3) Theme: Impact on professional socialisation and identity

One medical student with a university degree subject unrelated to natural science or health identified himself and his peers in similar personal circumstances as ‘non-science’ graduates towards the start of his graduate-entry medicine degree programme. He perceived there was an unequal playing field between medical students from ‘non-science’ and ‘science’ degree background in terms of their baseline scientific knowledge. He found the first year medical curriculum had assumed too much prior scientific knowledge from ‘non-science’ students who may not always understand the basic scientific concepts the medical school faculty assumed they had already learnt. Thus, he had to undertake additional study of secondary school learning materials to build up his baseline medical science knowledge. Medical students from non-science and non-health profession background may perceive they were at a relative knowledge base and self-confidence disadvantage as compared to their peers that had been health professionals. Medical students that were health professionals generally did not find patient contact a challenging experience. However, the quality of their patient encounters during the early stages of their graduate-entry medicine degree programme could differ significantly from their prior experience as health professionals. One medical student described during medical school teaching sessions, doctors taught medical students about individual body systems using patients as models. This approach was seen as impersonal and differed significantly from the holistic approach to patient care she had delivered when she worked as a health professional.

4) Theme: Impact on collaborative learning

There was a strong emphasis on group work and collaborative learning in the first year of their graduate-entry medicine degree programme. The diversity of medical students in the medical school, especially with those from health profession background, could be very helpful when medical students learn together as they could draw on the strengths and prior knowledge of their peers to support and supplement their own learning.

III. MY REFLECTIONS

The entry requirement into United Kingdom graduate-entry medicine degree programmes varied between medical schools. Some medical schools accepted graduates from any degree subject while others only accepted graduates with a science or relevant health-related degree subject. Despite the small study sample, medical students participated in this study were found to have originated from a diverse range of demographic, education and employment background, which included three medical students with non-science and non-health related first degrees. In keeping with the findings by Rapport and colleagues (2009), my study findings also found the prior experience of medical students conferred them with generic transferrable skillset that increased their preparedness for student life in medical school. For example, prior educational experiences could be associated with increased skills confidence related to working in groups, using a computer, write assignments, participate in class and asking for help (Byrne et al., 2012). Adding to the study findings by Rapport and colleagues (2009), and Gallagher and Hoare (2016), my study findings suggested that some of medical students’ prior education and employment experience could be directly relevant to the learning outcomes of their medical school curriculum.

Some medical students from non-science or non-health profession background were concerned about their baseline knowledge and confidence difference to their peers that were health professionals. Potential solutions to address their concern could involve the provision of targeted learning guidance and academic support prior to or at the early stages of their degree programme. Medical students that were health professionals could also benefit from receiving learning guidance about the quality of their patient encounter in medical school was likely to be significantly different from their previous experience as a health professional.

This study has its limitations. This is a single centre study with a small sample size and it only explored the impact of academic and professional experience on their medical school journey. Social desirability bias and recall bias may affect the responses study participants provide. Future research could explore the impact of carer experience of students with dependents on their medical school journey.

Notes On Contributor

Simon Tso is currently studying towards a doctoral (MD) degree at the University of Warwick, United Kingdom. He is a Fellow of the Higher Education Academy and a dermatology registrar training at the Department of Dermatology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom.

Ethical Approval

This study was a part of a larger study investigating the experience of graduate-entry medicine degree programme students, which has received ethical approval from a local research ethics committee.

Acknowledgement

The author 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 and Dr William Hunt for his comments on the draft manuscript.

Funding

This study was a 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 author has no conflicts of interest, including no financial, consultant, institutional and other relationships that might lead to bias.

References

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa.

Byrne, M., Flood, B., Hassall, T., Joyce, J., Arquero, J. L., González-González, J. M., & Tourna-Germanou, E. (2012). Motivations, expectations and preparedness for higher education: A study of accounting students in Ireland, the UK, Spain and Greece. Accounting Forum, 36(2), 134-144. https://doi.org/10.1016/j.accfor.2011.12.001.

Gallagher, P., & Hoare, K. (2016). Transition: Health professionals as medical students. Clinical Teacher, 13(3), 223-226. https://doi.org/10.1111/tct.12415.

Garrud, P. (2011). ‘Who applies and who gets admitted to UK graduate entry medicine? – An analysis of UK admission statistics’. BioMed Central Medical Education, 11(1), 71. https://doi.org/10.1186/1472-6920-11-71.

Rapport, F., Jones, G. F., Favell, S., Bailey, J., Gray, L., Manning, A., … Williams, R. (2009). ‘What influences student experience of graduate entry medicine? Qualitative findings from Swansea school of medicine’. Medical Teacher, 31(12), e580–e585. https://doi.org/10.3109/01421590903193570.

*Dr Simon Tso
Email: simontso@doctors.org.uk
University Hospital Coventry
Clifford Bridge Road
Coventry
CV2 2DX

Published online: 2 January, TAPS 2019, 4(1), 59-61
DOI:https://doi.org/10.29060/TAPS.2019-4-1/PV1076

Oh Moh Chay

Department of Paediatrics, Respiratory Medicine Services, KK Women’s and Children’s Hospital, Singapore

I. INTRODUCTION

Over the years, medical education has invariably changed. When faculty meet to discuss the performance and attitude of young doctors, the question of what had happened to medical education often arise, intuitively pointing fingers to changes in medical education as the root cause of the problem.

Three significant changes were evident. The first was transformation of the traditional curriculum where there was clear demarcation between preclinical and clinical years to a revised curriculum with integration of the basic sciences and clinical training. The second was the shift from the teacher centric didactic teaching style to a student centric framework, incorporating a wide array of instructional and assessment methods. The other important transformation was the emergence of Innovation Technology (IT) in medical education and the healthcare environment. This article represented personal reflections on the transformation in Medical Education over the past 4-5 decades, through the lens of a clinician, how in my personal opinion, these changes may have affected the educational outcome.

II. UNDERGRADUATE TRAINING

In the traditional curriculum, in preclinical years, medical students who had to learn basic sciences such as anatomy and embryology, would be left struggling to find the relevance of the teaching to subsequent medical practice. In adult learning theory, understanding the relevance of the subject played an important role in retention of knowledge (Knowles, 1984). Thus the change to an integrated curriculum incorporating science and clinical should be was a move in right direction. In the 70s’ if there was a curriculum, it was very opaque to the students and the clinical teachers. Since, there was no “declared curriculum”, clinical teachers and students focused on teaching/acquiring medical knowledge in the “real world”, the clinical environment. Resources were limited, students were dependent on the recommended standard and reference textbook. The clinical teachers were an invaluable resource for knowledge and skills. Tutorials were infrequent and usually held in large groups. Small clinical group were assigned to one tutor for the whole posting. This was really valuable as the tutor knew the group’s strengths and weakness and worked along students to improve the gaps. Tutors had high expectation that the students must know the patients in the ward. Everything seen in ward was deemed to be of learning value. There was no structured teaching on how to gather history or communicate with patients; no practice course on clinical skills. While in clinical posting, students observed the house officer at work. From the house staff, students learn how to clerk a patient, order the investigations and to carry out the immediate management. Learners very much depended on serendipity, observations and reflection to enhance their learning experience. Learning was opportunistic and depending on enthusiasm of the students and staff in the wards. This resulted in autonomous learning. This informal learning was critical to enhance the tacit knowledge. As the students spent majority of the time immersed in the real clinical environment, students observed, and had time to reflect on the experience. Experiential learning and reflection are important in deep learning and better understanding, retention of knowledge and critical to professional practice (Kolb, 1984; Mann, Gordon, & MacLeod, 2009). Experiential learning in a rich clinical environment with the high index of unpredictability might have also resulted in the better resilience of the students in unpredictable real life situations in the healthcare environment.

Over the last 3 decades, there was a shift to more structured curriculum with emphasis on a transparent curriculum. This was the era where many learning theories were conceptualised and thus curriculum development to facilitate learning. Teaching methods evolved from didactic to more interactive, blended teaching and encompassed both team based and problem based learning strategies. I was curious while problem based learning and team based learning facilitate group of students to learn together and leverage on each other’s strengths, there is little activity to promote interprofessional learning.

Assessments were diversified from pivotal on knowledge and clinical skills to include wider competence such as communication and professionalism. Assessments were mapped to the transparent curriculum. Unfortunately, from students’ perspective, the education outcome was primarily focused on passing the examination. Assessment drives behaviour. Thus the learning styles of the medical students focus on what was helpful to pass the OSCE examination, to ensure the checklist was ticked to optimize the scores. Students now differential the experience in ward to learning and non-learning value. The richness and authenticity of the clinical environment was “adulterated”. While the move to include more core competencies was laudable, creating a divide between learning value and non-learning value had reduced the exposure of the students to the “unpredictability” in the clinical environment. Would this “education environment” be preparing the new graduates well for their role in postgraduate years 1?

III. POSTGRADUATE TRAINING

Whilst the transformation was happening to the undergraduate education, there was a quiet front in postgraduate education for period of time, with only minor changes observed. It was only in the recent 10 years that postgraduate training underwent rapid changes.

School of Post Graduate Medical Studies was established in 1970. Back then, specialist training did not begin with medical graduation. Doctors were tested in the real world clinical environment before they embark on pursuing a career in specialist training. There was the local Master Examination which was helmed by Joint Commission of Specialist Training (JCST). Initially, there was no structured curriculum. Training was time based. After an individual completed a stipulated months of clinical attachment with apprenticeship style learning and passed the required clinical examination, you could practise as a specialist. It was not until 1990s that an advanced training program was formalised. The 3 years advanced Paediatrics training was started in 1991. Over the years, a formal curriculum and other requirements besides medical knowledge and clinical skills were slowly introduced. Paediatrics moved from Basic Specialist Training and Advanced Specialist to seamless training in 2008. During this period the training committee had seen a need to move from time based to competency based training. The medical community had observed that time based training, in face of the new environment and new generation of learners might not be optimal to train the future specialists. Some clearly needing more time in training. Hence, the move to competency based outcome.

In 2010, Ministry of Health made a decision that specialist training to be aligned with Accreditation Council Graduate Medical Education International (ACGME-I) standards. That was the beginning of a concerted effort to adapt the 6 ACGME competencies as the desired outcomes for specialist training. Besides clinical skills and medical knowledge, communication and interpersonal skills, professionalism, practice-based learning and improvement, and system-based practice were introduced to the curriculum. These changes may be challenging but recognised as were important aspects of holistic education of a healthcare professional whom life- long learning and improvement is critical to quality medical practice.

The other change was the shift from faculty centric to learner centric. In particular, the emphasis on feedback by residents on the teachers and the program performance, had resulted in concerns among the clinical educators who queried the usefulness and accuracy of these feedback and the concern that faculty/program would be doing what’s favourable in the learner’s perspectives instead of focusing on the right thing to do for the residents.

IV. MOVING FORWARD

In an era where change is a predictable constant, and with the healthcare environment getting increasing complex and rapidly changing, transformation in medical education is inevitable. The healthcare standards and the health of the nation hinged on the outcome of medical education. For past decades, demographic and disease pattern had changed. IT had made the learning/teaching different and the ability to memorise huge chunks of data, no longer essential. With emerging epidemic of chronic disease related to lifestyle, the focus of training should shift to meet the needs of future generation with anticipatory and community rather than hospital care. Healthcare providers must be cognizant and be able to use IT freely. Diagnostic tests revolutionised the high dependency on clinical skills in physical examination in the past. Thus, changes in the curriculum and teaching methodology to train future ready healthcare providers is necessary. Methods of assessment must be in tandem to nurture the right behaviours.

Notes On Contributor

Dr Chay graduated from University of Singapore in 1976. She been practising in field of Paediatric Medicine since 1979. She also has leadership roles in Medical Administration and Education.

Acknowledgement

Professor Low Poh Sim for her assistance in the preparation of this manuscript.

Funding

Professor Low Poh Sim for her assistance in the preparation of this manuscript.

Declaration of Interest

Author declares there is no conflict of interest.

References

Knowles, M. S. (1984). Androgogy in action: Applying modern principles of adult learning (The Jossey-Bass Management Series). San Francisco: Jossey-Bass.

Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall.

Mann, K., Gordon, J. & MacLeod, A. (2007). Reflection and reflective practice in health professions education: A systematic review. Advances in Health Sciences Education, 14(4), 595-621.

*Chay Oh Moh
Email: chay.oh.moh@singhealth.com.sg
Telephone: +65 6392 6358
Address: 100 Bukit Timah Road,
Singapore 229899