Submitted: 20 July 2020
Accepted: 6 November 2020
Published online: 13 July, TAPS 2021, 6(3), 14-23
https://doi.org/10.29060/TAPS.2021-6-3/RA2346

Claude Jeffrey Renaud¹, Zhi Xiong Chen^2,6, Heng-Wai Yuen³, Lay Ling Tan⁴, Terry Ling Te Pan⁵ & Dujeepa D. Samarasekera⁶

¹Department of Medicine, Khoo Teck Puat Hospital, Singapore; ²Department of Physiology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ³Department of Otorhinolaryngology-Head & Neck Surgery, Changi General Hospital, Singapore; ⁴Department of Psychological Medicine, Changi General Hospital, Singapore; ⁵Department of Anaesthesiology, National University Health System, Singapore; ⁶Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Abstract

Introduction: The Coronavirus-19 pandemic has had profound effects on health professions education (HPE) posing serious challenges to the continued provision and implementation of undergraduate, postgraduate and continuing medical education (CME). Across these HPE domains, the major disruptions included the exclusion of undergraduate learners from clinical learning environments, restricted intra-, inter-institutional and overseas movement of medical professionals, termination of face-to-face learner-educator interactions, deployment of postgraduate learners into non-scope service settings, and CME postponement.

Methods: In this review we report on how in Singapore various adaptive measures were instituted across the 3 HPE domains at institutional and national level to maintain adequate resources at the frontline to meet service exigencies, promote healthcare professionals’ wellbeing and safety as well as mitigate the spread of the pandemic.

Results: We identified several strategies and contingencies developed to address these challenges. These involved the use of online learning platforms, distributed and asynchronous learning, an undergraduate Pathway Programme, and use of innovative hands-on technology like simulation. Robust, well pre-planned pandemic preparedness, effective communication, as well as provision of psychological support resources ensured maintenance of service and academic continuity, trust and resilience within HPE. However, several challenges remain, namely the timing and manner of conducting formative and summative assessments, cybersecurity, and the indispensable hands-on, in-person experiential learning for surgical training.

Conclusion: Strong leadership with vision and planning, good communication, prioritising learners’ and educators’ wellbeing and safety, and harnessing existing and emerging online learning technologies are crucial elements for effective contingencies for HPE disruption during pandemics.

Keywords:           Pandemic Preparedness, COVID-19, Curriculum Development, Online Learning and Assessment, Learner Wellbeing and Safety, Health Profession Education

Practice Highlights

• COVID-19 pandemic has caused profound disruption to medical education and Singapore is no exception.
• Health professions education community (undergraduate, residency and continuous professional development) had to rethink traditional learning approaches.
• There is a need for contingencies that integrate service and academic continuity and safety.
• Implementing contingencies requires coordinated national and institutional pandemic pre-preparedness.
• There remain uncertainties as to the long-term effectiveness of these contingencies on learning.

I. INTRODUCTION

Singapore had its first case of Coronavirus 19 (COVID-19) on 23rd January 2020 and scaled up its response from DORSCON (Disease Outbreak Response System Condition) Yellow to Orange 2 weeks later as the crisis evolved to pandemic proportion (Ashokka et al., 2020; J.E.L. Wong et al., 2020). This involved setting up a suite of strategies aimed at containing community transmission (Lee et al., 2020).

At the healthcare service and health profession education (HPE) level, these strategies centred on mobilising adequate resources at the frontline, mandating use of personal protective equipment (PPE) in high-risk areas and restricting healthcare workers’ movement (Ashokka et al., 2020; Lee et al., 2020; Liang et al., 2020; C. Wong et al., 2020; J.E.L. Wong et al., 2020). In addition, undergraduate medical education put a stop to clinical clerkships and large and small on-campus learning and restructured formative and summative assessments.

As the very stakeholders and resources required for HPE were diverted to fighting the pandemic, HPE faced extraordinary disruption. Educators and learners had to delicately balance service continuity, patients’ and learners’ wellbeing and safety versus maintaining a business-as-usual approach to learning. Moreso, the entire HPE community had to critically relook at the applicability of competency-based learning which is traditionally predicated on the principles of authentic supervised patient experience, programmatic assessment, learners as part of a community of practice and continuous professional development (CPD) (Harris et al., 2010; Iobst et al., 2010).

Previous public health emergencies like Severe Acute Respiratory Syndrome (SARS) have taught that such disruptions can provide unique opportunities for contingency planning in HPE especially when there is little time for wholesale programme redesign (Lim et al., 2009; Patil & Yan, 2003). This report thus describes the experience of 3 HPE domains in Singapore in mitigating the dissonance between optimal pandemic preparedness, unconstrained academic continuity and learners’ and educators’ well-being.

 II. METHODS

A comprehensive review of the adaptive contingency strategies adopted at 1 undergraduate (Yong Loo Lin School of Medicine), Singapore residency programmes and across the CPD was made by looking at institutional and governmental programmes during the early phase of the pandemic and prevalent COVID-19 related literature on HPE. As this research is a description of events that have already happened and did not involve HPE stakeholders’ directly and interventionally, participants’ informed consent and internal review board approval were not required for its conduct.

III. RESULTS

Herein, is a detailed outline of the contingencies implemented across the 3 HPE domains which are also summarised in Table 1.

At the Yong Loo Lin School of Medicine which is the largest of the three medical schools in Singapore, the Education Team led by the Vice Dean (Education) started preparing in February 2020 for the possibility of loss of clinical teaching. Those most affected would be Phase 3 and 4 (Year 3 and 4) medical students. Phase 5 (Year 5) students were preparing for their Final Professional Examinations even though assessment was significantly disrupted across all Phases. Phase 1 and 2 (Year 1 and 2) students have relatively less clinical learning exposure and assessments, and were finishing their curricula and preparing for exams. Focusing on the Phase 3 and 4 students, first, their vacation and elective periods were brought forward respectively. Next, to give students meaningful learning opportunities that do not require patient contact, the Pathway Programme which had been launched before the pandemic was paced up (National University Singapore, Yong Yoo Lin School of Medicine, 2020).

The Pathway Programme consists of six Pathways. They are Health and Humanity, Health Informatics, Inquiry and Thinking, Medical Education and Medical Innovation and Entrepreneurship all led by a team of trained educationists. In addition, a non-Pathway initiative called Education Innovation completed the suite of new education offerings for the students. The sixth Pathway Behavioural and Implementation Science was partially offered under Inquiry and Thinking through a series of lectures on Health Economics. Below we describe what each Pathway is about.

1) Behavioral and implementation science: This pathway exposes medical students to principles of behavioural and implementation science, and applies this knowledge to effectively design and deliver healthcare in real-world settings, and lays the foundation for them to become active agents of change in clinical practice.

2) Health and humanity: This pathway aims to nurture emotionally resilient, socially conscious and globally minded health leaders through rekindling one’s love for medicine and humanity. Through experiential activities, inspirational workshops and hands-on project work in the community, students develop critical thinking skills in global health, teamwork and leadership skills to inspire health for all.

3) Health informatics: This pathway aims to enable students to gather and critically evaluate research and health informatics data, equipping them with the skills necessary to apply the principles of health informatics, summarise and visualise datasets to perform basic analyses, so they become data-science competent clinicians who can identify and analyse medical data to address clinical issues.

4) Inquiry and thinking: This pathway aims to inspire and motivate our medical students to develop a sense of curiosity so as to foster a habit of inquiry that is able to dynamically utilise a range of thinking methods, processes and skillsets to tackle questions and problems. The end goal of this pathway is to groom a pipeline of thinking doctors who can advance healthcare in any aspect they desire.

5) Medical education: This pathway exposes medical students to concepts and principles in HPE, to equip them with foundational skills in HPE, with a focus on educational innovation and scholarship of teaching and learning, so as to groom future clinical educators.

6) Medical innovation and entrepreneurship: This pathway aims to nurture medical students with the 6Cs attributes: Curiosity, Creativity, Compassion, Collegiality, Collaboration, and Commercial Intelligence. The programme gradually exposes medical students to concepts and principles in innovation, and the selective elements equip students with foundational skills in innovation and entrepreneurship.

With the elective period brought forward, Phase 4 students were exposed to the Pathway Programme from early-March to early-May 2020 through two weeks of front-loading online lectures, followed by four to eight weeks of projects. Most Pathways followed the general structure with slight variations between them. For Phase 3 students, they enjoyed an early vacation before encountering a shortened Pathway Programme from early-April to early-May 2020, comprising of 2 weeks of front-loading online lectures and 2 weeks of projects, which students had the option of continuing into Phase 4.

Using Inquiry and Thinking Pathway as an example, topics of front-loading online lectures included ‘Complexity and Systems Thinking’, ‘Habits of Inquiry and Critical Thinking’ and ‘Evidence-based Medicine and Search Methods’. More than 80 projects were offered by prospective supervisors with more than 70 students getting involved in projects. Each student was guided in the project by the supervisor as well as engaged in a one to two-hour weekly reflection sessions with a separate mentor or the supervisor who doubled up as a mentor. Students were required to submit a weekly reflection write-up of 50 words or more. At the end of the Pathway Programme, students submitted a single slide of their projects for evaluation. Top two projects from each Pathway were selected to present and compete in a Grand Finale on 8 May 2020 before the School’s leadership, a panel of judges, their peers and overseas observers. The Grand Finale attracted over 200 participants. Single slides of all projects were compiled into an e-book to be shared with students and faculty members.

B. Postgraduate Training: Experience of Residency Programmes across Singapore Three Sponsoring Institutions (SIs)

Since SARS, Singapore has steadily been bolstering critical resource reserves and expertise in pandemic preparedness, culminating in the setup of the 330-bed  purpose-built National Centre for Infectious Diseases (NCID) at the National Healthcare Group (NHG) Novena campus (Lee et al., 2020; Seah, 2020). Concurrently, postgraduate medical education underwent significant transformation with the adoption of Accreditation Council for Graduate Medical Education (ACGME) styled competency-based learning, culminating in the setup of three residency SIs of  which NHG is one (Huggan et al., 2012; Khoo et al., 2014). Thus during the build-up to COVID-19 pandemic,  NCID, residents and faculty at NHG 27 residency programmes formed the initial frontliners in managing the pandemic  before being later joined by the other two SIs (C. Wong et al., 2020).

Care delivery and learning had to be restructured so that adequate manpower could be redeployed at screening centres, emergency departments, outbreak wards and critical care units. Frontline residents had to endure long and exhausting shifts wearing PPEs and prolonged time away from family, not to mention postponed leaves. Residents and faculty also had to be segregated into independent two-team system with phased two-weekly rotations to avoid manpower attrition and service disruption as a result of staff infection, quarantine or burnout. Elective surgeries, continuity clinics, grand rounds, face-to-face case conferences, cross-institutional elective rotations, in-person programme selection interviews as well as summative assessment had to be deferred. Postgraduate specialty conferences, courses and workshops, whether local or international, also had to be postponed or cancelled due to travel restrictions, further limiting opportunities for learning.

As a result of these changes several resourceful strategies were implemented to balance the palpable tensions between service, wellbeing and learning.

The first was maintaining open and transparent communication between institutional and academic leaders, faculty and residents so that the rationale for a pandemic-mode centralised command-control leadership model could be accepted. This allowed residents to grasp the real sense of urgency brought in by COVID-19, thus facilitating speedier buy-in and compliance to ever changing human resource and education policies.  In addition, this strategy helped build up trust in the institutional support structure and contain the spread of parallel distracting infodemics, allowing residents to focus on service delivery, learning and well-being.

The second strategy was the promotion of residents’ physical and psychological safety and wellbeing. This entailed ensuring all residents had adequate orientation to the proper use of PPEs and could easily access them.  Well-being and resilience support resources like in-person or anonymous virtual outreach psychological crisis intervention counselling and peer support through online debriefing and feedback were put in place across all hospitals under the three SIs. The ancillary effect was that residents felt their safety, their families’ and patients’ was valued and that there was fair and equitable work and rest allocation. Further, ACGME cancelled all accreditation and Clinical Learning Environment Review site visits and  took steps to reframe and relax some accreditation criteria (Nasca, 2020). This went a long way in allaying residents’ anxieties regarding clinical progression.

The third strategy was leveraging existing online tools to maintain some element of learning continuity without the need to invest in significantly expensive technologies, curricular redesign or faculty re-development.  Programmes transferred their core didactic lectures, journal clubs and case-based discussions onto distributed learning platforms such as Zoom, Go to meeting, Google meet or WebEx for synchronous learning.  Access to Webinars had the added advantage of providing opportunities for asynchronous learning. Zoom teleconferencing in particular, remains the most popular due to its affordable subscription, large participant capacity and easier accessible collaborative interface and a breakout feature that enables mounting learning models like team-based learning.

Residents from surgical residency programmes who rely on direct-patient encounter and hands-on experience for learning were more significantly impacted. Importantly, because non-emergency visits to hospitals were halted, elective procedures and surgeries were postponed or cancelled and, the number of patients and learning opportunities was thus greatly reduced. This was further aggravated by the shift of many training institutions and teaching hospitals to pandemic service (Liang et al., 2020). In many instances, surgical residents were redeployed to frontline areas, like screening centres, which are beyond their usual scope of practice (C. Wong et al., 2020).

Curriculum development contingencies thus went beyond online didactic content dissemination to  embrace enhanced distributed learning approaches like videos, podcasts, virtual reality and simulated learning (C. Wong et al., 2020). Some programmes improvised by forming on-call hybrid surgical teams, which allowed surgical residents some measure of hands-on exposure to generic emergency or semi-elective cases during on calls but not necessarily within the scope of their area of interest.

C. Contingencies for Continuous Professional Development (CPD)

The disruption brought on by closure of higher educational institutions, scaling down of healthcare organisations and travel restrictions, compelled educators and health care professionals to adapt and embrace curricular changes and transition to virtual learning and use of technology for simulated learning.

Continuing medical education (CME) and CPD are integral parts of the development of a healthcare professional in providing optimal clinical care for his/her patient. CME is aimed at maintaining or updating the requisite knowledge, skills, professional performance and relationships and crucially, is a requirement for maintenance of certification in the discipline or specialty of the healthcare profession (Davis et al., 2008). CPD on the other hand caters to a broader range of competencies that reflect  the  healthcare profession attitudes towards learning and learning needs (Filipe et al., 2018). Every specialty and governing medical body has its stipulated requirements.  In Singapore, the Singapore Medical Council (SMC) states that all fully and conditionally registered doctors are required to meet the compulsory CME requirements of 50 core points for the qualifying period before their practising certificate can be renewed (Singapore Medical Council, 2020a). While most CME activities involve attendance at local, regional or international scientific meetings or conferences, self-study, review and authorship of articles are also considered core CME points. Most hospitals hold regular Grand Ward Rounds, journal clubs and peer review learning sessions at departmental and institutional levels, which also contribute towards core CME points.

However, with Singapore moving to DORSCON Orange, many of these learning activities were immediately suspended as staff scrambled to reorganise clinical services amidst the pandemic imperative for team separation and safe distancing. Thus, traditional face-to-face meetings were replaced by online meetings and webinars facilitated by virtual platforms mentioned previously. In tandem the SMC relaxed requirements for CME credits by allowing healthcare professionals to log in attendance to online sessions, including webinars (Singapore Medical Council, 2020b). There was also an increase in allocation of CME credits for self-study (e.g., reading of referenced journals listed in PubMed). COVID-19-related CME activities were also considered core points for all doctors (Singapore Medical Council, 2020b).    

While, much of the recent global CME content has primarily focused on increasing understanding of COVID-19 and its infectious nature across various medical disciplines, there has been lesser emphasis on its medical and psychological impact to health. It has nonetheless enabled healthcare professionals to better provide optimal care for patients while adopting best available evidenced practice relating to all aspects of this rapidly contagious disease. Thus, online information dissemination has been at an unprecedented high with multiple local, regional and international webinars and resource websites being made readily accessible. Professional societies have also made available to their members regularly curated digital speciality-specific resources on best practices pertaining to COVID-19 management (Academy of Medicine Singapore, 2020).

In addition to CME, healthcare professionals have traditionally relied on annual live face-to-face local, regional and international scientific conferences, symposiums, and educational workshops to network as a learning community and keep abreast of domain-specific advances. With strict travel restrictions these have been cancelled, postponed or moved online as webinars, interactive content, forums and chats. 

Some conference organisers decided to still proceed to issue notices of acceptance of abstract submissions as ‘proof’ of scholarly work or allowed online presentation.  Other creative ways of continuing with international conferences have included a “blended conference” approach with a mix of face-to-face and online content to support those attending onsite and online (Nadarajah et al., 2020). With careful attention paid to safe distancing for onsite participants, such “blended conferences” provide the all-important human face-to-face interactions which online webinars and conferences, though functional in most parts, sorely lack. They also provide the best of both worlds and may indeed be the new normal in the foreseeable future as COVID-19 further changes the HPE landscape relating to international travel and social interaction. 

Similarly, Singapore’s three medical school curriculum development centres rapidly transited in-person to virtual faculty development sessions. This allowed educators openly dispersed by social distancing and clinical exigencies to continue tapping on the best pedagogic practices, interact and engage in interprofessional learning.

IV. DISCUSSION

The COVID-19 pandemic disruptions have reinforced the need for agency and adaptation in HPE. We have shown that through well-coordinated, multisectoral efforts, solutions can be harnessed to minimise their negative impact on learning. However COVID-19, unlike other recent coronavirus epidemics like SARS and Middle East Respiratory Syndrome (MERS) seems a more formidable crisis (Jones, 2020; Peeri et al., 2020). It may not go away quickly without the advent of effective vaccines and sustained infection control measures. These contingencies are therefore aimed at promoting service and academic continuity, safety and resilience. Whilst they are useful blueprints for pandemic preparedness and responsiveness in the short term, they may not be applicable in all contexts or in a crisis of attrition. Further, they have their own strengths and limitations.

A major strength is institutional and academic leaders’ sense of long-term planning and commitment to educators’ and learners’ safety through effective communication, being visible and providing programme and system support. In a rapidly evolving disruptive environment, this is crucial, as stakeholders remain engaged and trusting without having to anguish over under-resourcing or abandonment. Recent publications have alluded to the social capital returns of such an  “integrative resilience approach” that amplifies individual and system wellbeing and minimises burn-out and contagion (Neufeld & Malin, 2020; Samarasekera et al., 2020; Schwartz et al., 2020; Wald, 2020).

Another strength is the adoption of adaptive online technologies which not only ensures academic continuity but also allows a smooth and rapid quarantine and pandemic curriculum development. Large virtual communities of learners can thus be rapidly mobilised without fundamentally affecting content, quality and institutional bottom lines. Indeed, this may have had the unintended consequences of unprecedentedly boosting attendance rates in medical schools, residency programmes and CPD sessions. Online migration also  facilitates quick and mass standardised training and deployment of untrained or returning retired healthcare professionals in general and critical care medicine, allowing healthcare institutions to boost capacity in those critical areas during pandemics (Brunner et al., 2020; Li et al., 2020). More so, these emergent technologies hold a lot of promise for post-pandemic medical education and replication of authentic patient experiences. It is envisioned that they can be interfaced onto learning management systems (LMS) and  into areas like virtual patient consults, telemedicine, adaptive learning and extended reality or avatar-like high fidelity simulation (Goh & Sandars, 2020). They are also important as a source of asynchronous learning whereby learners who are too busy with clinical duties or  for surgical residents when there is a lack of critical hands- on training (Tolu et al., 2020).

A third strength, is that such crisis can open unintended opportunities for learners to develop competencies outside the core curricular knowledge and procedural skills sphere. For instance, the mere exposure  of undergraduate learners not directly involved in patient care to pandemic-related content, volunteering in contact tracing or public awareness centres or restructuring of learning experiences like the Pathway Programme can nurture professional identity, pandemic literacy and doctor-ready qualities like  service prioritisation, altruism and resilience (Bauchner & Sharfstein, 2020; Rose, 2020; Stetson et al., 2020). Indeed, the Pathway Programme succeeded in meaningfully engaging medical students at a time when clinical teaching and clinical elective opportunities were frozen. It gave time for the medical school to work out a safe and calibrated approach to resume clinical training in consultation with the relevant government bodies. The fact that it was conceptualised pre-pandemic demonstrates an extraordinary sense of prescience by the academic leadership. The advent of COVID-19 served to accelerate its implementation. It thus not only helped undergraduate medical education to cope with the pandemic but enrich the medical curriculum by catering to the diverse strengths and interests of each learner in order to nurture future-ready doctors for a post-COVID world.

As to residents’ learning,  negotiating challenging pandemic duty rosters, making personal choices and sacrifices, navigating processes like resource allocation and public health measures and being deployed into non-core areas, can be just-in-time learning platforms for more nuanced ACGME competencies like professionalism, interpersonal and communication skills,  system-based practice and practice-based learning (Hall et al., 2020; Nasca, 2020; Schwartz et al., 2020; Tolu et al., 2020; C. Wong et al., 2020). For surgical residents, there is also an added learning and safety benefit when hitherto straightforward surgical procedures like tracheostomy suddenly come with a myriad of precautions, criteria, and protocols (Givi et al., 2020). Clinic and elective surgery postponement can provide ample opportunities for self-directed learning, exit exams preparation and scholarly pursuits like grant, research ventures and quality improvement projects writing (Schwartz et al., 2020; Tolu et al., 2020). Additionally, prioritisation of public health emergency response training across the HPE spectrum can render healthcare institutions better prepared at handling future pandemics and burn-out (Yang et al., 2020).

Nevertheless, these contingencies have a number of limitations. Namely, moving medical education from the bedside to the ‘web-side’ cannot replace the real patient-centred clinical experience and case-mix learners derive from ward rounds, grand rounds and continuity clinics. Even the Pathway Programme was not without its challenges. With Singapore entering into Circuit Breaker phase of DORSCON Orange on 3^rd April 2020, some projects were disrupted as access and movement became more limited (Ministry of Health Singapore, 2020).

Secondly, the utility of online learning is very much predicated on the vagaries of internet penetration and connectivity which makes this approach not always transferable to all socio-economic contexts (Cecilio-Fernandes et al., 2020). More so, for surgical residents, online learning or high-fidelity simulation cannot substitute for in-person learning. The technical skills, haptic feedback, the realism of live surgery, the experiential and contextual learning of ‘being there’ in a surgical team, and the non-cognitive domain skills like collaboration and resilience can be hard to simulate. Reduced contact time between residents and faculty also impacts adversely on opportunities for mentoring, role modelling and supervision. There is also always a danger of  breaching learning principles such as cognitive overload when  online content design is outside the hands of curriculum developers and programme directors (Kachra & Ma, 2020). As to health professionals, most of these online CME resources represent rather an amalgam of available information that may not have been well curated and pre-approved by accreditation organisations for relevancy.

Thirdly, the contingencies fail to address the enormous challenges in conducting clinical workplace-based assessments, without compromising their validity, reliability, defensibility and educational impact.  Although  high-stakes OSCE can be successfully conducted in a pandemic environment, its implementation comes with tremendous logistical and political manoeuvring to ensure students’, examiners’ and patients’ safety and assessment integrity are preserved (Boursicot et al., 2020). Cancelling both formative and summative assessments can delay learners’ progression or completion unless adjustments are made to previously established competency criteria. Undergraduates may fail to graduate on time to join the vital pool of medical workforce and residents may not be able to practise as independent practitioners. This can create anxiety and concern to both learners and educators about how to catch up post-pandemic with piling assessment and case and portfolio backlogs.

Lastly,  reliance on third party software entities for online content dissemination contrary to institution-designed LMS or whole-sale programme information technology infrastructure redesign  carries cybersecurity, privacy and data ownership risks (Fawns et al., 2020; Sandars et al., 2020). Not all faculty are tech savvy to handle the technical intricacies and the many options in the market.  Predatory providers may thus seek to peddle behaviourist tactics onto users for their own corporate gains.

 V. CONCLUSION

In summary, the COVID-19 pandemic has been a major threat to HPE in Singapore but it has also created opportunities for adaptive and flexible contingencies so that learning goes on safely with minimum constraints. While there is a need to celebrate these early successes, it is also imperative that we assess and learn from their limitations so that we can further refine and more successfully, collaboratively and iteratively apply them in a prolonged crisis. Furthermore, these experiences can serve as templates for adaptive and value-added learning at both regional and international HPE settings beset by larger service and academic disruption. But most importantly they foreshadow the resilience, reimagining and resourcefulness that are expected of HPE as it transits from the new normal of pandemic crisis management to the post-pandemic next normal of innovative technology-based learning.

Notes on Contributors

Adj Associate Professor Claude J Renaud  is a senior consultant nephrologist at Khoo Teck Puat hospital Singapre and Associate Programme Director at the National Healthcare Group Renal Residency Programme. He conceptualised, drafted and revised  article and wrote introduction, postgraduate medical education (PGME), discussion and conclusion sections.

Dr Zhi Xiong Chen is a Senior Lecturer in Physiology and Assistant Dean for Education at Yong Loo Lin School of Medicine, National University of Singapore. He conceptualised article and wrote the undergraduate medical education section.

Adj Associate Professor Heng Wai Yuen is senior consultant in the Department of Otorhinolaryngology-Head & Neck Surgery, Changi General Hospital,  Singapore  and Campus Director, SingHealth Duke-NUS Institute for Medical Simulation (SIMS). He wrote abstract and post graduate medical education sections and revised article.

Adj Associate Professor Tan Lay Ling is senior consultant  in the Department of Psychological Medicine, Psychogeriatric Service, at Changi General Hospital (CGH). She wrote the section on continuous professional development and revised article overall.

Dr  Terry Ling Te Pan is a Senior Consultant, Department of Anaesthesia, National University Hospital and Advisor, Education Technology Unit, Yong Loo Lin School of Medicine, National University of Singapore. He co-wrote the section on continuous professional development and revised article overall.

Dr Dujeepa D. Samarasekera, director at  Centre for Medical Education (CenMED) Yong Loo Lin School of Medicine, National University of Singapore. conceptualised and revised article.

Ethical Approval

This study  is a description of events and practices and therefore did not require approval from institutional review boards.

Funding

There is no external funding involved in this study.

Declaration of Interest

Other than Dr Dujeepa D Samarasekera who is Editor of TAPS, all authors have no conflict of interest, including financial, consultant, institutional and other relationships that might lead to bias.

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*Claude J Renaud
Department of Medicine, 
Division of Renal Medicine,
Khoo Teck Puat Hospital,
90 Yishun Central, Singapore 768828
Email: jeffrey.renaud@ktph.com.sg

Submitted: 4 August 2020
Accepted: 14 October 2020
Published online: 4 May, TAPS 2021, 6(2), 1-8
https://doi.org/10.29060/TAPS.2021-6-2/RA2370

Tow Keang Lim

Department of Medicine, National University Hospital, Singapore

Abstract

Introduction: Clinical diagnosis is a pivotal and highly valued skill in medical practice. Most current interventions for teaching and improving diagnostic reasoning are based on the dual process model of cognition. Recent studies which have applied the popular dual process model to improve diagnostic performance by “Cognitive De-biasing” in clinicians have yielded disappointing results. Thus, it may be appropriate to also consider alternative models of cognitive processing in the teaching and practice of clinical reasoning.

Methods: This is critical-narrative review of the predictive brain model.

Results: The theory of predictive brains is a general, unified and integrated model of cognitive processing based on recent advances in the neurosciences. The predictive brain is characterised as an adaptive, generative, energy-frugal, context-sensitive action-orientated, probabilistic, predictive engine. It responds only to predictive errors and learns by iterative predictive error management, processing and hierarchical neural coding. 

Conclusion: The default cognitive mode of predictive processing may account for the failure of de-biasing since it is not thermodynamically frugal and thus, may not be sustainable in routine practice. Exploiting predictive brains by employing language to optimise metacognition may be a way forward. 

Keywords:            Diagnosis, Bias, Dual Process Theory, Predictive Brains

Practice Highlights

• According to the dual process model of cognition diagnostic errors are caused by bias reasoning.
• Interventions to improve diagnosis based on “Cognitive De-biasing” methods report disappointing results.
• The predict brain is a unified model of cognition which accounts for diagnostic errors, the failure of “Cognitive De-biasing” and may point to effective solutions.
• Using appropriate language as simple rules or thumb, to fine-tune predictive processing meta-cognitively may be a practical strategy to improve diagnostic problem solving.

Core features of the predictive brain model	Clinical reasoning features and processes
The frugal brain and free energy principle(Friston, 2010)	Cognitive load in problem solving (Young et al., 2014)
Iterative matching of top down priors Vs bottom up signals	Inductive foraging (Donner-Banzhoff & Hertwig, 2014; Donner-Banzhoff et al., 2017)
Predictive error processing	Pattern recognition in diagnosis
Recognition-expectation-based signal suppression	Premature closure (Blissett & Sibbald, 2017; Melo et al., 2017)
Hierarchical predictive error coding as learning	Development of illness scripts (Custers, 2014)
Probabilistic-Bayesian inferential approximations	Bayesian inference in clinical reasoning
Context sensitivity	Contextual factors in diagnostic errors(Durning et al., 2010)
Action orientation	Foraging behaviour in clinical diagnosis (Donner-Banzhoff & Hertwig, 2014; Donner-Banzhoff et al., 2017)
Interoception and affect in prediction error management	Gut feel and regret (metacognition)
The precision(reliability/uncertainty) of prediction errors	Clinical uncertainty (metacognition) (Bhise et al., 2017; Simpkin & Schwartzstein, 2016)

Table 1: Core features of the predictive brain model of cognition manifested as clinical reasoning processes

Legend to Figure 1

A summary of the cognitive processes engaged by the predict brain model during clinical diagnosis

A: Active search for diagnostic clues based on prior experience of similar patients in similar situations.

B: Recognition of key features will activate a series of familiar illness script from long term memory to match with the new case.  If this is successful, a diagnosis made and any prediction error signals are rapidly silenced.

C & D: When the illness scripts do not match the presenting features (????), cognition slows down, attention is heightened and further searches are made for additional matching clues and illness scripts. This is iterated                until a satisfactory match is found or a new illness script is generated to account for the mismatch.

E: A new variation in the presenting features for that disease is then encoded in memory as a new illness script in memory and thus, a valuable learning moment.

F: The degree of uncertainty or level of confidence in matching key presenting features to a diagnosis is a meta-cognitive skill and a critical expertise in clinical diagnosis. This corresponds to the precision or gain/weightage of prediction errors (Meta cognition) in the predictive brain model.

Figure 1: A summary of the cognitive processes engaged by the predict brain model during clinical diagnosis

Thermodynamic frugality is a central feature of the predictive brain model and in this system, the primacy of attending only to surprises or PEs is pivotal (Friston, 2010). This might be regard as an energy efficient strategy in coping with cognitive load which has been long recognised as an important consideration in clinical problem solving and learning (Young et al., 2014; Van Merrienboer & Sweller, 2010).

From the first moments of a diagnostic encounter the clinician is alert to clues which might point to the diagnosis and begins to generate possible diagnosis scenarios and simulations based upon her prior experience of similar patients and situations (Donner-Banzhoff & Hertwig, 2014). This is iterative and, from a scanty set of presenting features, a plausible diagnosis may be considered within a few seconds to minutes (Donner-Banzhoff & Hertwig, 2014; Donner-Banzhoff et al., 2017). Thus, a familiar illness script is activated from long term memory to match with the new case (Custers, 2014). If this is successful, a particular diagnosis is recognised and any PE signal is rapidly silenced. Functional MRI studies of clinicians during this process showed that highly salient diagnostic information, reducing uncertainty about the diagnosis, rapidly decreased monitoring activity in the frontoparietal attentional network and may contribute to premature diagnostic closure, an important cause of diagnostic errors (Melo et al., 2017). This may be considered a form of diagnosis or recognition related PE signal suppression analogous to the well know phenomenon of repetitive suppression (Blissett & Sibbald, 2017; Bunzeck & Thiel, 2016; Krupat et al., 2017).

In cases where the illness scripts do not match the presenting features, a PE event is encountered, cognition slows down, attention is heightened and further searches are made for additional matching clues and illness scripts (Custers, 2014). This is iterated until a satisfactory match is found or a new illness script is generated to account for the mismatch. This is then encoded in memory as a new variation in the presenting features for that disease and thus, a valuable learning moment. Bayesian inference is a fundamental feature of both clinical diagnostic reasoning and the predictive brain model (Chater & Oaksford, 2008).

As in the predictive brain model, external contextual factors and internal emotional and physiological responses such as gut feeling and regret, exert profound effects on clinical decision making (M. Djulbegovic et al., 2015; Durning et al., 2010; Stolper & van de Wiel, 2014; Stolper et al., 2014). Also active inductive foraging behaviour in searching for diagnostic clues described in experienced primary physicians is analogous to behaviour directed at reducing PEs (Donner-Banzhoff & Hertwig, 2014; Donner-Banzhoff et al., 2017). The precision or gain/weightage of PEs is manifested metacognitively as uncertainties or levels of confidence in clinical reasoning (Sandved-Smith et al., 2020). Metacognition is a critical capacity and expertise in effective decision making. (Bhise et al., 2017; Fleming & Frith, 2014; Simpkin & Schwartzstein, 2016).

C. Why Applying the Dual Process Model May Not Improve Clinical Reasoning

Recent studies which have applied the popular dual process model to improve diagnostic performance by “cognitive de-biasing” in clinicians have yielded disappointing results (G. R. Norman et al., 2017). Cognitive processing of the predictive brain as the dominant default network mode of operation may account for this setback since de-biasing is not naturistic, requires retrospective “off line” processing after the monitoring salience network has already shut off (Krupat et al., 2017; Melo et al., 2017). It is not thermodynamically frugal and thus, may not be sustainable in routine practice (Friston, 2010; Young et al., 2014). Even Daniel Kahneman himself admits that, despite decades of research in cognitive bias he is unable to exert agency of the moment and de-bias himself (Kahneman, 2013). This will be more so in novice diagnosticians in the training phase who have scanty illness scripts and limited tolerance of any further cognitive loading (Young et al., 2014). The failure to even identify cognitive biases reliably by clinicians due to hindsight bias itself suggests that this intervention will be the least effective one in improving diagnostic reasoning (Zwaan et al., 2016).

 D. Using Words to Fine Tune the Precision of Diagnostic Prediction Error

Daniel Kahneman, the foremost expert on cognitive bias, cautions that, contrary to what some experts in medical education advice, avoiding bias is ineffective in improving decision making under uncertainty (Restrepo et al., 2020). By contrast he suggested that we apply simple, common sense, rules of thumb (Kahneman et al., 2016). I hypothesise that instructing clinical trainees to use appropriate words to self in the diagnostic setting during active, naturalistic PE processing before the diagnosis is made and not as a retrospective counter check to cognition afterwards may be a way forward (Betz et al., 2019; Clark, 2016; Lupyan, 2017). In a multi-center, iterative thematic content analysis of over 2,000 cases of diagnostic errors with a structured taxonomy, Schiff and colleagues identified a limited number of pitfall themes which were overlooked and predisposed physicians to reasoning errors (Reyes Nieva H et al., 2017). These pitfall themes included three which are of particular interest in relation to naturalistic PE processing namely: (1) counter diagnostic cues, (2) things that do not fit and (3) red flags (Reyes Nieva H et al., 2017). Thus, we instructed our student interns and internal medicine residents to pay particular attend to these three diagnostic pitfalls during review of new patients and clinical problems (Lim & Teoh, 2018). They were required to append the following sub-headings to their clerking impression in the patient’s electronic health record (eHR): (a) Counter diagnostic features; (b) Things that do not fit; (c) Red flags. This template was added after the resident had entered his or her numerated list of diagnoses or issues. “Counter diagnostic features” was defined as symptoms, signs or investigations which were inconsistent with the proposed primary diagnosis. “Things that do not fit” was defined as any finding that could not be reasonably accounted for taking into account the main and differential diagnoses. “Red flags” were defined as findings which raised the possibility of a more serious underlying illness requiring early diagnosis or intervention. The attending physicians were required, during bedside rounds, to give feedback on these points and make amendments to the eHR as appropriate. This exercise may give us an opportunity to see if we can improve diagnostic accuracy by using pivotal words-to-self in the appropriate setting to maintain cognitive openness, flexibility and thus, avoid premature (Krupat et al., 2017). It is also a valuable critical, metacognitive thinking habit to inculcate in tyro diagnosticians (Carpenter et al., 2019).

IV. CONCLUSION

The theory of predictive brains has emerged as a major narrative in the understanding of how our mind works. It may account for the limitations of interventions designed to improve diagnostic problem solving which are based on the dual process theory of cognition. Exploiting predictive brains by employing language to optimise metacognition may be a way forward.

Note on Contributor

Lim designed the paper, reviewed the literature, drafted and revised it.

Ethical Approval

There is no ethical approval associated with this paper.

Funding

No funding sources are associated with this paper. 

Declaration of Interest

No conflicts of interest are associated with this paper. 

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*Lim Tow Keang
Department of Medicine 
National University Hospital
5 Lower Kent Ridge Rd
Singapore 119074
Email: mdclimtk@nus.edu.sg

Submitted: 4 May 2020
Accepted: 3 August 2020
Published online: 5 January, TAPS 2021, 6(1), 3-29
https://doi.org/10.29060/TAPS.2021-6-1/RA2351

Elisha Wan Ying Chia^1,2, Huixin Huang^1,2, Sherill Goh^1,2, Marlyn Tracy Peries^1,2, Charlotte Cheuk Yiu Lee^2,3, Lorraine Hui En Tan^1,2, Michelle Shi Qing Khoo^1,2, Kuang Teck Tay^1,2, Yun Ting Ong^1,2, Wei Qiang Lim^1,2, Xiu Hui Tan^1,2, Yao Hao Teo^1,2, Cheryl Shumin Kow^1,2, Annelissa Mien Chew Chin⁴, Min Chiam⁵, Jamie Xuelian Zhou^2,6,7 & Lalit Kumar Radha Krishna^1,2,5,7-10

¹Yong Loo Lin School of Medicine, National University of Singapore, Singapore; ²Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore; ³Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore; ⁴Medical Library, National University of Singapore Libraries, National University of Singapore, Singapore; ⁵Division of Cancer Education, National Cancer Centre Singapore, Singapore; ⁶Lien Centre of Palliative Care, Duke-NUS Graduate Medical School, Singapore; ⁷Duke-NUS Graduate Medical School, Singapore; ⁸Centre for Biomedical Ethics, National University of Singapore, Singapore; ⁹Palliative Care Institute Liverpool, Academic Palliative & End of Life Care Centre, University of Liverpool; ¹⁰PalC, The Palliative Care Centre for Excellence in Research and Education, Singapore

Abstract

Introduction: Whilst the importance of effective communications in facilitating good clinical decision-making and ensuring effective patient and family-centred outcomes in Intensive Care Units (ICU)s has been underscored amidst the global COVID-19 pandemic, training and assessment of communication skills for healthcare professionals (HCPs) in ICUs remain unstructured

Methods: To enhance the transparency and reproducibility, Krishna’s Systematic Evidenced Based Approach (SEBA) guided Systematic Scoping Review (SSR), is employed to scrutinise what is known about teaching and evaluating communication training programmes for HCPs in the ICU setting. SEBA sees use of a structured search strategy involving eight bibliographic databases, the employ of a team of researchers to tabulate and summarise the included articles and two other teams to carry out content and thematic analysis the included articles and comparison of these independent findings and construction of a framework for the discussion that is overseen by the independent expert team.

Results: 9532 abstracts were identified, 239 articles were reviewed, and 63 articles were included and analysed. Four similar themes and categories were identified. These were strategies employed to teach communication, factors affecting communication training, strategies employed to evaluate communication and outcomes of communication training.  

Conclusion: This SEBA guided SSR suggests that ICU communications training must involve a structured, multimodal approach to training. This must be accompanied by robust methods of assessment and personalised timely feedback and support for the trainees. Such an approach will equip HCPs with greater confidence and prepare them for a variety of settings, including that of the evolving COVID-19 pandemic.

Keywords:           Communication, Intensive Care Unit, Assessment, Skills Training, Evaluation, COVID-19, Medical Education

Practice Highlights

• The global COVID-19 pandemic has underscored the importance of effective communications in the Intensive Care Unit (ICU).
• ICU communications training should adopt a longitudinal, structured and multimodal approach.
• Robust stepwise evaluation of learner outcomes via Kirkpatrick’s Hierarchy is needed.
• Supportive host organisation and conducive learning environment and are key to successful curricula.

I. INTRODUCTION

The COVID-19 pandemic has placed immense strain on intensive care units (ICU)s with healthcare teams and resources stretched to meet the sudden increased healthcare demands of critically ill patients. To further complicate the situation, ICU teams are called to not only communicate closely with colleagues in a bid to support them but also counsel families confronting acute distress and uneasy waits separated from their loved ones due to restrictions to visiting in an effort to limit the spread of this pandemic (Ministry of Health, 2020; World Health, 2020). From breaking bad news (Blackhall, Erickson, Brashers, Owen, & Thomas, 2014; J. Yuen & Carrington Reid, 2011), to conveying the need for sedation and intubation (Carrillo Izquierdo, Diaz Agea, Jimenez Rodriguez , Leal Costa, & Sanchez Exposito, 2018) and providing progress reports on critically ill patients (Curtis et al., 2005; Curtis, White, Curtis, & White, 2008; Yang et al., 2020), communication skills amongst ICU healthcare professionals (HCPs) are pivotal in reassuring anxious, emotional and stressed patients and families (Ahrens, Yancey, & Kollef, 2003; Foa et al., 2016; Kirchhoff et al., 2002). Good communication in the ICU has also been shown to improve patient-physician relationships (K. G. Anderson & Milic, 2017), patient and family-centred outcomes, quality of care, and patient and family satisfaction (Bloomer, Endacott, Ranse, & Coombs, 2017; Cao et al., 2018; Currey, Oldland, Considine, Glanville, & Story, 2015). Effective communications between HCPs in ICU also enhances clinical decision-making (Kleinpell, 2014), reduces medication and treatment errors (Clark, Squire, Heyme, Mickle, & Petrie, 2009; Happ et al., 2014; Sandahl et al., 2013), decreases physician burnout (Rachwal et al., 2018), and improves staff retention and satisfaction (Hope et al., 2015).

With evidence suggesting that poor communication skills (Downar, Knickle, Granton, & Hawryluck, 2012; Foa et al., 2016) and training (Smith, O’Sullivan, Lo, & Chen, 2013) are likely to increase patients’ (Dithole, Sibanda, Moleki, & Thupayagale ‐ Tshweneagae, 2016) and families’ (Curtis et al., 2008) stress, adversely affect care and recovery (Dithole et al., 2016), and increase healthcare costs (Kalocsai et al., 2018), some authors have suggested that effective communication skills are at least as important (Adams, Mannix, & Harrington, 2017; Cicekci et al., 2017; Van Mol, Boeter, Verharen, & Nijkamp, 2014) to good patient care as clinical acumen (Curtis et al., 2001a). Yet despite evidence of the importance of communication skills in ICU, communication skills training remains inconsistent, variable and not evidence-based in most ICU settings (Adams et al., 2017; Berlacher, Arnold, Reitschuler-Cross, Teuteberg, & Teuteberg, 2017; Bloomer et al., 2017; D. A. Boyle et al., 2017; Miller et al., 2018; Sanchez Exposito et al., 2018).

With this in mind, a systematic scoping review (SSR) is proposed to map current approaches to communications skills training in ICUs (Munn et al., 2018) and potentially guide design of a communications training programme. An SSR allows for systematic extraction and synthesis of actionable and applicable information whilst summarising available literature across a wide range of pedagogies and practice settings employed to understand what is known about teaching and evaluating communication training programmes for HCPs in the ICU setting (Munn et al., 2018).

 II. METHODS

To overcome concerns about the transparency and reproducibility of SSR, a novel approach called Krishna’s Systematic Evidenced Based Approach (henceforth SEBA) is proposed (Kow et al., 2020; Krishna et al., 2020; Ngiam et al., 2020). This SEBA guided SSR (henceforth SSRs in SEBA) adopts a constructivist perspective to map this complex topic from multiple angles (Popay et al., 2006) whilst a relativist lens helps account for variability in communication skills training (Crotty, 1998; Ford, Downey, Engelberg, Back, & Curtis, 2012; Pring, 2000; Schick-Makaroff, MacDonald, Plummer, Burgess, & Neander, 2016).

To provide a balanced review, the research team was supported by the medical librarians from the National University of Singapore’s (NUS) Yong Loo Lin School of Medicine (YLLSoM), the National Cancer Centre Singapore (NCCS) and local educational experts and clinicians at the NCCS, the Palliative Care Institute Liverpool, YLLSoM and Duke-NUS Medical School (henceforth the expert team). The research and expert teams adopted an interpretivist approach as they proceeded through the five stages of SEBA (Figure 1).

Figure 1. The SEBA Process

A. Stage 1: Systematic Approach

1) Determining the title and research question: The research and expert teams agreed upon the goals, population, context and concept to be evaluated in this SSR. The two teams then agreed that the primary research question should be “What is known about teaching and evaluating communication training programs for HCPs in the ICU setting?” The secondary research questions were “How are communication skills taught and assessed in the ICU setting?” and “How effective have such interventions been as described in the published literature?”

2) Inclusion criteria: A Population, Intervention, Comparison, Outcome, Study Design (PICOS) format was adopted to guide the research process (Peters, Godfrey, Khalil, et al., 2015a; Peters, Godfrey, McInerney, et al., 2015b) (Table 1).

PICOS	Inclusion Criteria	Exclusion Criteria
Population	·       Undergraduate and postgraduate healthcare providers (e.g. doctors, medical students, nurses, social workers) within ICU setting ·       ICU settings including medical, surgical, cardiology and neurology ICU ·       Communication between healthcare providers and patients in the ICU, or between healthcare providers in the ICU and patients’ families ·       Communication between or within healthcare providers’ teams in the ICU	·       Articles focusing solely on neonatal/ paediatric ICU setting ·       Articles focusing solely on speech therapy/ physical therapy/ occupational therapy ·       Non-ICU settings (e.g. general wards, emergency department) ·       Non-medical professions (e.g. Science, Veterinary, Dentistry) ·       Communication carried out over technological platforms
Intervention	·       Need for/ importance of interventions to teach communication in ICU setting ·       Facilitators and barriers to teaching communication in ICU setting ·       Recommendations, interventions, methods (e.g. tools, simulations, videos), curriculum content and assessments used for teaching communication in ICU setting
Comparison	·       Comparisons of various interventions, methods, curricula and evaluation methods used to teach or assess communication in ICU setting and its impact upon patients, healthcare providers, healthcare, and society
Outcome	·       Impact of interventions on patients, healthcare providers, healthcare, and society ·       Evaluation methods to assess interventions, methods, or curriculum used to teach communication
Study design	·       Articles in English or translated to English ·       All study designs including: o    Mixed methods research, meta-analyses, systematic reviews, randomised controlled trials, cohort studies, case-control studies, cross-sectional studies, and descriptive papers o    Case reports and series, ideas, editorials, and perspectives ·       Publication dates: 1st January 2000 – 31st December 2019 ·       Databases: PubMed, ERIC, JSTOR, Embase, CinaHL, Scopus, PsycINFO, Google Scholar

Table 1. PICOS

Nine members of the research team carried out independent searches for articles published between 1st January 2000 – 31st December 2019 in eight bibliographic databases (PubMed, ERIC, JSTOR, Embase, CINAHL, Scopus, Psycinfo and Google Scholar). The searches were carried out between 27th January 2020 and 14th February 2020. The PubMed search strategy can be found in Supplementary Material A. An independent hand search was done to identify key articles.

3) Extracting and charting: Nine members of the research team independently reviewed the titles and abstracts identified and created individual lists of titles to be included which were discussed online. Consensus was achieved on the final list of articles to be included using (Sambunjak, Straus, & Marusic, 2010)’s “negotiated consensual validation” approach through collaborative discussion and negotiation on points of disagreement on online meetings.

B. Stage 2. Split Approach

Working in three independent groups, the reviewers analysed the included articles using the ‘split approach’ (Ng et al., 2020). In one group, four researchers independently reviewed and summarised all the included articles in keeping with according recommendations set out by Wong, Greenhalgh, Westhorp, Buckingham, and Pawson (2013)’s “RAMESES publication standards: meta-narrative reviews” and Popay et al. (2006)’s “Guidance on the conduct of narrative synthesis in systematic reviews”. The four research team members then discussed their individual findings at online meetings and employed ‘negotiated consensual validation’ to achieve consensus on the tabulated summaries (Sambunjak et al., 2010). The tabulated summaries served to highlight key points from the included articles.

The four members of the research team also employed the Medical Education Research Study Quality Instrument (MERSQI) (Reed et al., 2008) and the Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Tong, Sainsbury, & Craig, 2007) also evaluated the quality of qualitative and quantitative studies included in this review.

Concurrently, the second group of five researchers analysed all the included articles using (Braun & Clarke, 2006)’s approach to thematic analysis then discussed their individual findings at online meetings and employed ‘negotiated consensual validation’ to achieve consensus on the final themes (Sambunjak et al., 2010). The third group of four researchers employed Hsieh and Shannon (2005)’s approach to directed content analysis to independently analyse all the included articles, discussed their independent findings online and employed ‘negotiated consensual validation’ to achieve consensus on the final themes (Sambunjak et al., 2010). This split approach consisting of the tabulated summaries and concurrent thematic analysis and content analysis enhances the reliability of the analyses. The tabulated summaries also help ensure that important themes are not lost.

1) Thematic analysis: Phase 1 of Braun and Clarke (2006)’s approach saw the team ‘actively’ reading the included articles to find meaning and patterns in the data. In phase 2, ‘codes’ were constructed from the ‘surface’ meaning (Braun & Clarke, 2006; Sawatsky, Parekh, Muula, Mbata, & Bui, 2016; Voloch, Judd, & Sakamoto, 2007) and collated into a code book to code and analyse the rest of the articles using an iterative step-by-step process. As new codes emerged, these were associated with previous codes and concepts (Price & Schofield, 2015). In phase 3, the categories were organised into themes that best depict the data. In phase 4, the themes were refined to best represent the whole data set and discussed. In phase 5, the research team discussed the results of their independent analysis online and at reviewer meetings. “Negotiated consensual validation” was used to determine a final list of themes (Sambunjak et al., 2010).

2) Directed content analysis: Hsieh and Shannon (2005)’s approach to directed content analysis (Hsieh & Shannon, 2005) was employed in three stages.

Using deductive category application (Elo & Kyngäs, 2008; Wagner-Menghin, de Bruin, & van Merriënboer, 2016), the first stage (Mayring, 2004; Wagner-Menghin et al., 2016) saw codes drawn from the article “Enhancing collaborative communication of nurse and physician leadership into two intensive care units” (D. K. Boyle & Kochinda, 2004). Drawing upon Mayring (2004)’s account, each code was defined in the code book that contained “explicit examples, definitions and rules” drawn from the data. The code book served to guide the subsequent coding process.

Stage 2 saw the four reviewers using the ‘code book’ to independently extract and code the relevant data from the included articles. Any relevant data not captured by these codes were assigned a new code that was also described in the code book. In keeping with deductive category application (Wagner-Menghin et al., 2016), coding categories and their definitions were revised. The final codes were compared and discussed with the final author to enhance the reliability of the process (Wagner-Menghin et al., 2016). The final author checked the primary data sources to ensure that the codes made sense and were consistently employed. The reviewers and the final author used “negotiated consensual validation” to resolve any differences in the coding (Sambunjak et al., 2010). The final categories were selected (Neal, Neal, Lawlor, Mills, & McAlindon, 2018) based on whether they appeared in more than 70% of the articles reviewed (Curtis et al., 2001b; Humble, 2009).

The narrative produced was guided by the Best Evidence Medical Education (BEME) Collaboration guide (Haig & Dozier, 2003) and the STORIES (Structured approach to the Reporting In healthcare education of Evidence Synthesis) statement (Gordon & Gibbs, 2014).

III. RESULTS

9532 abstracts were identified from ten databases, 239 articles reviewed, and 63 articles were included as shown in Figure 2 (Moher, Liberati, Tetzlaff, & Altman, 2009).

Figure 2. PRISMA Flowchart

3) Comparisons between summaries of the included articles, thematic analysis and directed content analysis: In keeping with SEBA approach the findings of each arm of the split approach was discussed amongst the research and expert teams. The themes identified using Braun and Clarke (2006)’s approach to thematic analysis were how to teach and evaluate communication training in ICU and the factors affecting training.

The categories identified using Hsieh and Shannon (2005)’s approach to directed content analysis were 1) strategies employed to teach communication, 2) factors affecting communication training, 3) strategies employed to evaluate communication, and 4) outcomes of communication training. These categories reflected the major issues identified in the tabulated summaries.

These findings were reviewed with the expert team who agreed that given that the themes identified could be encapsulated by the categories identified, the categories and the themes will be presented together.

a) Strategies employed to teach communication in ICU: 61 articles described various interventions used to teach communication in the ICU. 19 involved ICU physicians, 18 involved ICU nurses, 4 saw participation of ICU physicians and nurses, 13 included the multidisciplinary team in the ICU, 1 was aimed at medical interns, 2 at medical students, 2 at nursing students, and 2 at both medical and nursing students. Given the overlap between teaching strategies, topics taught, and assessment methods employed in ICU communication training for nurses, doctors, nursing and medical students and HCPs in the literature, we discuss and generalise the results across HCPs.    

In curriculum design, seven studies (D. K. Boyle & Kochinda, 2004; Hope et al., 2015; Krimshtein et al., 2011; Lorin, Rho, Wisnivesky, & Nierman, 2006; McCallister, Gustin, Wells-Di Gregorio, Way, & Mastronarde, 2015; Miller et al., 2018; Sullivan, Rock, Gadmer, Norwich, & Schwartzstein, 2016) designed a curriculum based on extensive reviews of literature on teaching communication. Brunette and Thibodeau-Jarry (2017) used Kern’s 6-step approach to curriculum development to design a structured curriculum targeted at meeting the needs identified whilst Sullivan et al. (2016) and Lorin et al. (2006) used the authors’ own experiences in tandem with existing literature to guide curriculum design. W. G. Anderson et al. (2017) designed a communication training workshop based on behaviour theories whilst McCallister et al. (2015) based their curriculum on principles of shared decision-making and patient-centred communication. Northam, Hercelinskyj, Grealish, and Mak (2015) conducted a pilot study before implementing their intervention.

Topics included in the curriculum were categorised into “core topics”, or topics essential to the curriculum, and “advanced” which may be useful to incorporate into the curriculum. Core topics were deemed as topics that were most frequently cited in the literature or are crucial across a variety of interactions in the ICU setting such as history taking, relationship skills as well as on common scenarios in the ICU such as breaking bad news and communicating difficult decisions. “Advanced’ topics, though important, are not mentioned as frequently and appeared to be more site specific and sociocultural and ethical issues. These topics are outlined in Table 2 (full table with references found in Supplementary Material B). The methods employed are outlined in Table 3 (full table with references found in Supplementary Material C).

Published online: 7 January, TAPS 2020, 5(1), 8-15
DOI: https://doi.org/10.29060/TAPS.2020-5-1/RA2087

Justin Bilszta¹, Jayne Lysk¹, Ardi Findyartini² & Diantha Soemantri²

¹Department of Medical Education, Melbourne Medical School, University of Melbourne, Australia; ²Department of Medical Education, Faculty of Medicine, Universitas Indonesia, Indonesia

Abstract

Practice Highlights

• Successful transnational collaborative FDI requires genuine collaboration and partnership.
• Curriculum blueprinting with the awareness of cultural nuances is important for a collaborative FDI.
• Long-term sustainability needs to be considered and planned in light of the resource challenges.

I. INTRODUCTION

The opportunities to develop and foster collaborative partnerships across the globe in the field of higher education are growing. There are many forms of transnational collaboration in education; however, the majority of university collaborations are symbolised by ‘providers and buyers’, with buying countries being developing nations and provider countries based in developed ones (Nhan & Nguyen, 2018). This contrasts with non-economically driven forms of transnational collaboration which generally include partnerships looking to expand areas of research, knowledge or working on international curriculum (Carciun & Orosz, 2018), Regardless of the form, research into collaborative international partnerships reveal common challenges including issues of joint decision making, the different learning cultures and hierarchical structures, and sustainability of program outcomes (Allen, 2014; Caniglia et al., 2017; Kim, Lee, Park, & Shin, 2017; Sullivan, Forrester, & Al-Makhamreh, 2010; Yoon et al., 2016). This has implications for any new or emerging form of international collaboration and its continuing success.

One expanding area of non-economically driven transnational collaborations in higher education has been faculty development. These partnerships have been flourishing in many different disciplines and similar challenges concerning the establishment and long term sustainability have been identified. This paper contributes to the study of transnational collaborations in higher education by focusing specifically on faculty development in the field of medical education. It firstly reviews the challenges associated with international collaborations involved in faculty development. The authors then critically reflect on an example of an international collaboration between researchers from medical schools in Indonesia and Australia through the lens of the experiences of those involved.

Faculty development initiatives (FDIs) in medical schools are an inseparable part of the internationalisation of medical education (Harden, 2006). In this era of globalisation, medical faculty should be prepared to teach in a cross-cultural environment (Deardorff, 2009). International collaboration in FDIs aim to tackle challenges in resource and financial constraints as well as to increase the quality of programs by drawing on expertise and best evidence from different centres and countries (Burdick, Amaral, Campos, & Norcini, 2011; Burdick et al., 2010; Harden, 2006; Kim et al., 2015; Yoon et al., 2016). Despite the push to develop international collaborations in FDIs many countries, particularly those in developing nations, find this especially challenging (Kim et al., 2017; Sherman & Chappell, 2018) and there are several reasons for this. The first relates to the dominant model of foreign ownership and control. Whitehead et al. in their recent commentary on this issue highlighted the trend for educational collaborations to flow in one direction – Europe and North American to other parts of the world – with control of the curriculum and academic structures resting with the ‘foreign expert’ (Whitehead, Wondimagegn, Baheretibeb, & Brian, 2018). The second challenge centres around the limitations on the opportunities for faculty development because of heavy teaching loads, a lack of a well-trained faculty who can provide professional training, limited infrastructure and competing demands for research and clinical services (Alkan, 2000). The World Health Organization has recognised this critical problem for faculty development and its long term impact on creating a healthcare workforce fit for purpose in the 21st century (Buchan & Campbell, 2013). As clinical education changes health provider practice, it can have wide-ranging effects on the health of a population, especially in underdeveloped countries (Boulet, Bede, McKinley, & Norcini, 2007). Thus, FDIs must reflect the contexts and requirements of developing countries if they are to surmount these challenges.

Southeast Asia has its specific challenges that need to be recognised. Although in some countries it is heavily modelled on Western education systems, the medical education culture has innumerable adaptations and innovations with identified socio-economic, cultural and institutional barriers (Amin, 2004; Majumder, 2004). Cultural and community needs differ vastly and with one of the smallest number of medical schools per million population (Boulet et al., 2007), the lack of human and institutional capacity to satisfactorily address the healthcare needs of populations in this region is stark (Kanchanachitra et al., 2011). Although there are international FDIs provided by developed countries for academic institutions in Southeast Asia there is limited evidence as to their effectiveness and benefits to teaching practice gained by participants (Phuong, Duong, & McLean, 2015; Steinert et al., 2006). Other commonly cited challenges for FDI development include: a divide between the education contexts and expectations of Asian and Western countries (T. P. Lam & Y. Y. B. Lam, 2009); a lack of English ability which adversely impacts on establishing an effective international collaboration as well as in delivery of the FDI content to participants (Ferry et al., 2006); and where countries in Southeast Asia have tried to develop and implement their own FDIs (World Health Organization, 2013) insufficient resources and shortage of qualified educators result in significant limitations in achieving self-sufficiency.

II. CONTEXT

The Faculty of Medicine Universitas Indonesia (FMUI) and the Cipto Mangunkusumo Hospital, are committed to supporting the role of clinical teachers. An introductory FDI–Clinical Teacher Course (CTC)–has been available since 2008 to clinical teachers wanting to develop their teaching practice. The CTC is designed to support clinicians in the practical delivery of teaching and primarily focuses on the principles and techniques of teaching and supervising in clinical settings, the development of clinical reasoning skills, teaching procedural skills, and assessment practices in clinical settings. Training materials have been developed by the Department of Medical Education FMUI and the trainers are teaching staff from the Universitas Indonesia Academic Health System community. The CTC meets the provision of a minimum of 40 hours of training as regulated by the Directorate General of Higher Education, Ministry of Research and Higher Education and Universitas Indonesia.

In 2015, a formal collaboration (Partnerships in Clinical Education) between FMUI and the University of Melbourne (UoM) Medical School’s Excellence in Clinical Teaching (EXCITE) program was established. EXCITE is a series of linked award courses for clinical teachers from all health-related disciplines, that supports them in the practical delivery of teaching into the clinical workplace and provides a deeper understanding of the theories underpinning clinical education. A key aim of the FMUI–UoM collaboration was to develop an innovative and culturally relevant teaching program for clinical teachers from FMUI, that leveraged pedagogical strengths of the CTC and EXCITE programs and their teaching staff. The impetus for this collaboration was the long-standing professional relationships between academics from UoM and FMUI and was borne from FMUI recognising the need to develop, not just the practical delivery of teaching to their medical students, but opportunities for their clinical teachers to be exposed to cutting-edge clinical education practice. Importantly, any educational initiative needed to consider Indonesian academic and cultural traditions and be developed specifically for Indonesian clinical teachers, rather than simply transplanting or imposing an external (i.e. Western) teaching program ill-suited to the Indonesian context (Bleakley, Brice, & Bligh, 2008; Hodges, Maniate, Martimianakis, Alsuwaidan, & Segouin, 2009; Waterval, Frambach, Driessen, & Scherpbier, 2014).

III. AIMS AND OBJECTIVES

Much of the research into transnational collaborations have focused on the issue pertaining to quality assurance, regulation and accreditation of educational programs; translocation of curriculum and intercultural understanding; institutional and management strategic decision making; and student choice and academic mobility (Kosmützky & Putty, 2015). However, few studies have evaluated the critical factors for the success or failure of sustainable partnerships (Waterval, Driessen, Scherpbier, & Frambach, 2018; Waterval et al., 2014) particularly from the perspective of those who have negotiated the challenges of establishing such a transnational partnership. In this light, the focus of this paper is to provide the reader with insights on how to facilitate transnational collaboration viewed through the lens of the experiences of those involved. Its aim is not to provide a step-by-step process for the development of an FDI but critically reflect on the process by which the collaboration was established, and management of both the partnership and differences in context between medical schools in Indonesia and Australia. When read in conjunction with the companion paper published in the previous issue (Findyartini, Bilszta, Lysk, & Soemantri, 2019), we hope that the reader will gain an appreciation of better ways to foster transnational collaborations to drive educational reform.

IV. INSIGHTS

A. Insight 1 – Actively Foster Genuine Collaboration

Collaboration is a process of working together, which involves not only cooperation and communication, but also trust, respect and understanding, in order to establish an interdependent relationship that will augment the contributions of each party involved (Pike et al., 1993). As outlined, a key focus of the FMUI–UoM collaboration was to consider Indonesian academic and cultural traditions to develop an FDI specifically for Indonesian clinical teachers, rather than simply transplanting or imposing an external (i.e. Western) teaching model.

Research into successful international education partnerships has identified several key elements to ensure success with the most important of these being communication, mutual respect, humility and trust (Tupe, Kern, Salvant, & Talero, 2015). The relevance of a trusting relationship to collaborative performance has been repeatedly emphasised (Bachmann, 2001; Das & Teng, 2001; Fryxell, Dooley, & Vryza, 2002) and Bovill, Jordan, and Watters (2014) have highlighted that partners need to share a sense of mutual responsibility and benefit from a project, contribute expertise, effort and resource equally and for this contribution is to be recognised by the other partner (Bovill et al., 2015).

To ensure that externally the FMUI–UoM partnership was perceived as a genuine collaborative process, one of the very first initiatives undertaken was a needs assessment activity involving a broad mix of clinical teachers from FMUI. This activity was facilitated by staff from the FMUI Department of Medical Education with staff from UoM as active observers. This activity resulted in a mutual sharing of ideas and perspectives thereby allowing clinical teachers from FMUI to 1) share information on the current status of clinical teacher training at FMUI; 2) identify internal and external factors that influence the introduction and efficacy of FDIs at FMUI; 3) reach a consensus on practical visions of future health professions education at FUMI and; 4) discuss methods of delivering FDIs and the pros and cons of each format.

Whilst the focus of the needs assessment was to inform the development of the FDI, the learning for the research team was the importance of active engagement with clinical teaching leaders and a greater understanding for the UoM team of the cultural and academic context in which FMUI clinical teachers deliver their teaching activities. This led to a recognition of the cultural importance of negotiation and discussion when proposing change and of spending time in person and in location with those impacted by change (Tupe et al., 2015; Zhang & Huxham, 2009). Of significance, this activity emphasised the bilateral exchange of educational expertise and experiences rather than a unilateral flow of ideas, materials, and experts from one context (UoM) to another (FMUI) as well as the process of developing the collaborative partnership rather than concentrating merely on the educational product (Keay, May, & O’Mahony, 2014).

Importantly, a small but significant part of actively maintaining a collaborative mindset and approach was regular contact between the researchers, through both formal (e.g. email and exchanging documentation) and informal (e.g. social media) means. These methods of collaboration, whether scheduled or unscheduled, contributed to building and maintaining rapport which then enhanced mutual respect and co-construction of strategies and approaches to achieving the collaborative project goals.

B. Insight 2 – Utilise Curriculum Blueprinting as a Means Rather Than an End

There are three well-documented barriers to curriculum delivery in international partnerships–that a shared curriculum will inevitably result in a ‘variability in expectations, decision-making, and academic performance’ (Coleman, 2003, p. 359); content knowledge and delivery, and teaching skills, will differ between academic contexts (Heffernan & Poole, 2005; Shams & Huisman, 2012); and the inherent weakness of relying only on documents when engaging in curriculum mapping processes as these maps only describe what is intended to take place in the learning environment, not necessarily what does take place (Hays, 2016) and why.

To overcome these barriers a three-step process was undertaken using the paradigm of the designed-delivered-experienced curriculum (Prideaux, 2003): 1) a formalised curriculum blueprinting exercise comparing the CTC and EXCITE program at the Graduate Certificate level (i.e. the designed curriculum); 2) the curriculum map was then supplemented with experiences of the research team who had delivered into their respective FDIs (i.e. the delivered curriculum); and 3) acknowledging the experiences of participants of both FDIs (i.e. the experienced curriculum). This blueprinting activity highlighted areas of pedagogical similarities (e.g. the characteristics of providing effective feedback to students; using OSCEs to assess student performance in the clinical setting) and differences (e.g. engaging peers in a process of peer feedback of teaching) and provided a trigger for frank discussion and reflection, with both groups of researchers freely and honestly questioning the pedagogical decisions made for their individual FDIs. It was through this iterative process of challenge and reflexivity, rather than the blueprinting activity itself, that meant that decisions on the pedagogical framework and selection of teaching and learning activities and education resources was a collaborative and shared process.

Visualising the curriculum and making visible the structure of both programs made decisions related to modifying pedagogical approaches self-evident and consequently, the goals and objectives of the FDI become more important in guiding planning and development, rather than control of the content, and recognition that content can be represented and interpreted from multiple perspectives. Through this process, the curriculum blueprint represented the collaborative thought process used to establish the FDI. The presence of the document encouraged dynamic discussions among the researchers in attempting to create an evidence-based, best practice FDI while still considering the characteristics of those who would be participating.

C. Insight 3 – Awareness of Cultural Nuances is Vital

Successful international collaborations necessarily involve multiple interwoven dimensions of leadership, organisation, collaboration, and personal growth, the relevance of which is inseparable from society and social frameworks (Eldridge & Cranston, 2009). In the context of this project, not only did societal cultural differences have to be considered but also the different academic and clinical medicine and teaching cultures of Australia and Indonesia. When undertaking transnational teaching projects in other countries, it is important that the assumptions made about one’s own and others’ cultures are both questioned (Maher, Sicchia, & Stein, 2003). But this itself provides an opportunity to compare and contrast both cultures, thereby fostering greater understanding, and appreciation of, the nuances of both.

Although the researchers had well established professional and personal relationships and extensive knowledge of both countries and cultures, there was still a need–especially on the side of the UoM team–to observe the Indonesian academic culture in vivo and the interaction and relationships between faculty members from different clinical disciplines. This then needed to be overlayed with an understanding of the social structures which govern Indonesian life and the influences of factors such as age, gender and religious background on how individuals and communities of practice interact. As others have highlighted (Yudhi, Nanere, & Nsubuga-Kyobe, 2006) difficulties in negotiation between Indonesia and Australia can be avoided by having a better cultural understanding of each other.

The aforementioned needs analysis activity was an important lens through which the UoM researchers could observe how clinical teachers as individuals within FMUI interact, as well as how FMUI as an educational organisation functions. This was developed further when the FMUI researchers had the opportunity to audit the EXCITE Graduate Certificate in Clinical Teaching program. This allowed the FMUI researchers to observe the Australian context within the same paradigms as the UoM researchers had the Indonesian context. An outcome of this was the opportunity to compare, contrast and challenge perceptions about teaching and learning in both settings and how this is influenced by social and cultural norms. Extensive discussion within, and between, both teams of researchers were vitally important to explicitly examine, and challenge, established assumptions (Bleakley et al., 2008) around teaching in the clinical environment and the pedagogical structure of an FDI. Early and Ang’s (2003) model of cultural intelligence − cognition (‘do I know what is going on?), motivation (‘am I motivated to act?’ which the research teams re-visualised as ‘what needs to be changed?’) and behaviour (‘can I act appropriately and effectively?’ which again was re-visualised as ‘can I make change appropriately and effectively?’) − provided a framework for these discussions and led to a better understanding of the working context of both partners. As observed by others, the need for genuine respect for complex contexts, practices, and paradigms of thinking, as an integral part of developing cultural competence among the researches, cannot be overemphasised (Mertens, 2009).

D. Insight 4 – Actively Engage and Empower Colleagues to Champion the Work of the Transnational Collaboration

Developing collaborative partnerships based on sustainable equitable relationships in which sociocultural and power differences are acknowledged, demanded participation and a shared vision at every stage of the project (Heron & Reason, 2001). From the outset, both FMUI and UoM had an agreed goal to provide a pathway for FMUI clinical teachers to further develop their teaching practice including articulation into a higher degree program at UoM and/or advanced study in clinical teaching and clinical leadership delivered locally.

Success required, not just a program built on a sold and justifiable pedagogy but ‘buy-in’ from senior clinical teaching leaders who not only share a passion for teaching themselves, but also recognise the need to support the development of junior teachers by exposing them to innovative and best practice methods of teaching training; and long term sustainability through training a pool of FMUI education leaders who could not only deliver the FDI as designed but also make changes in response to feedback from both participants and local needs. Importantly, the collaborative partnership needed to acknowledge the hierarchical nature of academic culture in Indonesia. This type of academic culture has been recognised as a potential impediment to the selection of participants for FDIs as this can restrict the pool of participants because of screening by senior academics and administrators (Kim et al., 2017).

The 1st Advanced Clinical Teacher Training and Training on Trainers Workshop was an important step in ensuring senior clinical teaching/education leaders were involved in the process of developing the FDI, thereby becoming de facto members of the research team, and took ownership of the program structure and curriculum objectives. Importantly, these ‘champions’ were able to describe to their teaching colleagues that rather than a transplanted, imposed and/or culturally misaligned program, the newly developed FDI grew out of a shared desire to create a program developed specifically for Indonesian clinical teachers. At all times the researchers were aware of the risk of education imperialism (Bleakley et al., 2008) and the perception that the UoM approach was the only way to deliver an FDI. The ideas of Bruning, Schraw, and Ronning (1999) and Hodges et al. (2009) resonated with our thinking: that learning is highly dependent on individual and social context and activity (Bruning et al., 1999) and therefore by whose criteria should ‘standards…and other culturally specific constructions associated with the practice of medicine’ (Hodges et al., 2009, p. 916) be applied. It is only through having conversations that acknowledge and address these issues – with clinical teaching/education leaders as both participants of the FDI, as well future program leaders – are the seeds of long-term viability planted. These ‘champions’ become co-creators and owners of the program through active contribution, rather than simply passive recipients of learning.

The companion paper published in this issue explores in detail the experiences of participants from the Training on Trainers Workshop (Findyartini et al., 2019).

E. Insight 5 – Identify Resource Challenges to Implementation and Sustainability

Identifying challenges that impact on, and developing strategies to effectively utilise financial, institutional, and human resources, are vital to developing transnational collaborations that are sustainable (Wiek et al., 2013) and successfully capitalise on intercultural, linguistic, and national differences (Pashby & de Oliveira Andreotti, 2016). Caniglia et al. (2017) in their review of factors that influence sustainability in high education collaborations have identified resource allocation as an important consideration for the implementation of a transitional collaboration.

We would agree, but also argue that resource allocation is important for ensuring sustainability. One of the crucial aspects to the success of this project was the funding from the Australian-Indonesia Institute which allowed the research team to meet regularly face-to-face and attend activities in both countries. However, this grant was limited to costs associated with travel and accommodation and consequently much in-kind support was required from both institutions; for example, none of the costs associated with delivery of the Training the Trainer workshop was covered by the Australia–Indonesia Institute grant and expenses such as room hire, catering and photocopying were provided in-kind by FMUI senior management. Another factor which soon became evident was that much of the success of the collaboration depended on the researchers allocating time from other academic activities which could not be backfilled by other staff. This meant much of the time spent working on this project was after-hours or on the weekend. Further, the involvement of administrative staff from both institutions was limited for similar reasons which meant most of the organisational workload also fell back on the researchers.

Although there is an acknowledgment that goodwill from senior management and a commitment to the partnership are important factors ensuring the success of transnational collaborations, very few studies have formally looked at this and to our knowledge, only one (Caniglia et al., 2017) has attempted to systematically evaluate challenges (such as those described above) and strategies related to financial, institutional, and human resources in relation to implementation and sustainability. Given our experiences of having to find the capacity to undertake tasks peripheral to, but important for the success of, the partnership described in this paper, we see an opportunity for further work in this area.

V. CONCLUSION

The approaches that were undertaken in this project actively sought to develop a non-economically driven partnership between universities from Indonesia and Australia. This focus on expanding knowledge and best-practice teaching training, rather than ‘selling of a product’, resulted in pathways of reciprocal learning, the development of new ways of thinking about clinical teacher training and a synergistic approach to designing and implementing a culturally resonant FDI. As a transnational collaboration, the context and requirements of the Indonesian partner were central to the quality of the FDI, and its sustainability. Shared experiences among the researchers and flexibility to implement the best evidence, with adaptation to local needs and values – often referred to as glocalisation – was a key to success. This, in conjunction with a constructivist approach to curriculum mapping, and negotiation over the pedagogical content of the curriculum, mitigated several challenges identified with establishing successful transnational educational collaborations.

Notes on Contributors

Dr Justin Bilszta is a Senior Lecturer in Medical Education, Department of Medical Education, Melbourne Medical School University of Melbourne.

Dr. Jayne Lysk is a Lecturer in Clinical Education, Department of Medical Education, Melbourne Medical School University of Melbourne.

Dr Ardi Findyartini is a Senior Lecturer in Medical Education, currently the Head of Department of Medical Education and Head of Medical Education Unit, Faculty of Medicine Universitas Indonesia.

Dr Diantha Soemantri is a Senior Lecturer in the Department of Medical Education and currently the Vice Director (Medical Education) of the Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine Universitas Indonesia.

Ethical Approval

Ethical approval is not required for a program evaluation type of study as employed in this paper.

Acknowledgements

The authors would like to thank the Faculty of Medicine, Universitas Indonesia and the Department of Medical Education, Melbourne Medical School, University of Melbourne for this support of this collaboration.

Funding

This project was supported by the Commonwealth of Australia through the Australia-Indonesia Institute of the Department of Foreign Affairs and Trade (Application No: AII00004 of AII Grant Round 1 2014). Generous in-kind support was provided by Faculty of Medicine, Universitas Indonesia and the Department of Medical Education, Melbourne Medical School, University of Melbourne.

Declaration of Interest

The authors declare that they have no conflict of interest.

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*Diantha Soemantri
Department of Medical Education,
Faculty of Medicine, Universitas Indonesia,
Salemba 6 Central Jakarta,
DKI Jakarta, Indonesia 10430
Email: diantha.soemantri@ui.ac.id
dianthasoemantri@yahoo.com