Who is an effective clinical teacher from the perspectives of medical students and residents?

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Submitted: 14 February 2020
Accepted: 1 July 2020
Published online: 5 January, TAPS 2021, 6(1), 40-48
https://doi.org/10.29060/TAPS.2021-6-1/OA2227

Shirley Beng Suat Ooi1,2, Clement Woon Teck Tan3,4 & Janneke M. Frambach5

1Emergency Medicine Department, National University Hospital, National University Health System, Singapore; 2Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 3Department of Ophthalmology, National University Hospital, National University Health System, Singapore; 4Yong Loo Lin School of Medicine, National University of Singapore, Singapore; 5School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands

Abstract

Introduction: Almost all published literature on effective clinical teachers were from western countries and only two compared medical students with residents. Hence, this study aims to explore the perceived characteristics of effective clinical teachers among medical students compared to residents graduating from an Asian medical school, and specifically whether there are differences between cognitive and non-cognitive domain skills, to inform faculty development.

Methods: This qualitative study was conducted at the National University Health System (NUHS), Singapore involving six final year medical students at the National University of Singapore, and six residents from the NUHS Residency programme. Analysis of the semi-structured one-on-one interviews was done using a 3-step approach based on principles of Grounded Theory.

Results: There are differences in the perceptions of effective clinical teachers between medical students and residents. Medical students valued a more didactic spoon-feeding type of teacher in their earlier clinical years. However final year medical students and residents valued feedback and role-modelling at clinical practice. The top two characteristics of approachability and passion for teaching are in the non-cognitive domains. These seem foundational and lead to the acquisition of effective teaching skills such as the ability to simplify complex concepts and creating a conducive learning environment. Being exam-oriented is a new characteristic not identified before in “Western-dominated” publications.

Conclusion: The results of this study will help to inform educators of the differences in a learner’s needs at different stages of their clinical development and to potentially adapt their teaching styles.

Keywords:           Clinical Teachers, Medical Students, Residents, Cognitive/Non-Cognitive, Asian Healthcare, Faculty Development

Practice Highlights

  • Approachability and teaching passion are foundational non-cognitive skills in effective clinical teachers.
  • These foundational skills are more important for undergraduate than postgraduate teaching.
  • Procedural residents can accept less ‘warm’ teachers if they can learn advanced clinical skills.
  • Medical students value didactic ‘spoon-feeding’ type of teachers in their earlier clinical years.
  • Final year medical students and residents value feedback and role-modelling at clinical practice.

I. INTRODUCTION

    “The transformation of our students requires the engagement of innovative and outstanding clinician-teachers who not only supervise students in their development of technical skills and applied knowledge but also serve as role models of the values and attributes of the profession and of the life of a professional” (Sutkin, Wagner, Harris, & Schiffer, 2008). This statement nicely encapsulates the very important role played by outstanding clinical teachers in helping students to ultimately become professionals with the attributes our healthcare system desires. Previous research has extensively investigated characteristics of effective clinical teachers to inform faculty development (e.g. Branch, Osterberg, & Weil, 2015; Hatem et al., 2011; Hillard, 1990; Kernan, Lee, Stone, Freudigman, & O’Connor, 2000; Paukert & Richards, 2000; Singh et al., 2013; Sutkin et al., 2008; White & Anderson, 1995). However, despite the large body of existing research on effective clinical teaching, two issues related to the needs of different groups of learners need further investigation to enable more tailored faculty development.

    First, effective clinical teaching may look different in undergraduate as compared with postgraduate education. In many healthcare institutions, clinical teachers are expected to teach across the medical education continuum, i.e., undergraduate medical students, graduate doctors in training, as well as part of continuing medical education, and teaching abilities are a necessary prerequisite in an academic environment (Hatem et al., 2011). Based on the conceptual framework of constructivism (Bednar, Cunningham, Duffy, & Perry, 1991)—­a theory which equates learning with creating meaning from experience or contextual learning­—Jonassen (1991) argues that constructive learning environments are most effective for acquiring knowledge in the advanced stage of knowledge, the stage between introductory and expert. According to Jonassen (1991), the initial or introductory stage of knowledge acquisition occurs when learners have very little directly transferable prior knowledge about a skill or content area. In this stage, knowledge is best acquired through more objectivistic approaches which can be described as ‘spoon-feeding’. Medical students in general would fit into this introductory stage, in varying degrees depending on their seniority and individual progress in learning. Jonassen’s (1991) second stage is advanced knowledge acquisition where the domains are ill-structured and more knowledge-based. This is in contrast to his third or final stage of knowledge acquisition of experts that require very little instructional support but are able to deal with elaborate structures, schematic patterns and seeing the interconnectedness in knowledge through experience. The stage of junior doctors in training would be fit into the second or advanced stage of learning. Constructivist teachers help students construct knowledge to become active learners rather than passive recipients of knowledge from the teachers or textbooks. In view of this constructivist framework, it appears logical to postulate that as medical students mature to become practicing doctors, their perceptions of effective clinical teachers may change from one who ‘spoon-feeds’ them with medical knowledge to one who encourages them to actively construct new meaning as they become clinically more experienced and have to deal with complex and ill-defined problems. Low, Khoo, Kuan, and Ooi (2020) showed that although the top four characteristics of effective medical teachers are consistent across all 5 years of medical school, characteristics that facilitate active learner participation are emphasised in the clinical years consistent with constructivist learning theory. However, as there is a paucity of comparative research on perceptions of effective clinical teachers among undergraduates as compared to postgraduates to plan more focused faculty development to address the attributes the learners look for in their clinical teachers, this warrants further research.

    The second issue relates to potential differences in the clinical teaching role between Asian and Western settings. In Western studies, as noted above, effective clinical teachers are encouraged to stimulate students’ intellectual curiosity leading to more self-directed learning (Hillard, 1990; Kernan et al., 2000; White & Anderson, 1995). In contrast, feelings of uncertainty about the independence required in self-directed learning, a focus on tradition that respects ‘old ways’, hierarchy expecting ‘truths’ to come from persons of higher status, and an achievement orientation to pass and excel in examinations have been identified as more prominent in non-Western than in Western cultures (Frambach, Driessen, Chan, & van der Vleuten, 2012). This is despite the recent introductions of more student-centred education methods. In Singapore for example, there is a move in the Yong Loo Lin School of Medicine (YLLSoM) to try to embed students into healthcare teams (Jacobs & Samarasekera, 2012) and implement newer methods of learning such as flipped classroom. However, many teachers still employ traditional methods of lectures and small group tutorials focused on exam preparation. A comprehensive review study of 68 articles on effective clinical teaching (Sutkin et al., 2008), comprised only one article that reported research from a non-Western setting (Elzubeir & Rizk, 2001). In this article, originating from the United Arab Emirates, there is no discussion on whether there is a difference in the perception of a role model between medical students in Asian countries compared to the West (Elzubeir & Rizk, 2001). Another study conducted in Asia showed differences in the perceptions of first-year and fifth-year medical students in Singapore on what makes an effective medical teacher (Kua, Voon, Tan, & Goh, 2006). More first-year students preferred handouts in contrast to fifth-year students who were less reliant on ‘spoon-feeding’. Research on effective clinical teaching is growing in the Asian setting (Ciraj et al., 2013;  Haider, Snead, & Bari, 2016; Kikukawa et al., 2013; Mohan & Chia, 2017; Nishiya et al., 2019; Venkataramani et al., 2016) though there is still a paucity of literature in the Asian setting compared with studies conducted in the West and there are none that directly compared medical students with residents.

    Another issue that deserves further attention is the role of non-cognitive domain skills in clinical teaching. Sutkin et al.’s (2008) review study described three main categories of characteristics of good clinical teachers: 1) physician characteristics, 2) teacher characteristics, and 3) human characteristics (Table 1). Approximately two-thirds of the characteristics were in non-cognitive domains (such as those involving relationship skills, emotional states, and personality types), and one-third in cognitive domains (such as those involving reasoning, memory, judgment, perception, and procedural skills). The article noted that cognitive abilities can be taught and learned, in contrast to non-cognitive attributes which are more difficult to develop and teach. Faculty development programmes currently often focus on traditional cognitive skills, such as curriculum design, large-group teaching, and assessment of learners (Searle, Hatem, Perkowski, & Wilkerson, 2006). In contrast, if non-cognitive domains are more important in contributing to outstanding teaching, they might need greater emphasis in the curricula of these workshops. The good news is that according to Schiffer, Rao, and Fogel (2003), non-cognitive behaviours are both measurable and alterable. Most of them have underlying neural networks which are entering our sphere of understanding. Hence non-cognitive skills, although much more challenging to develop than cognitive skills, have a potential to be developed. It is not clear whether there are differences in the distribution between cognitive and non-cognitive domains skills between the perceptions of medical students compared to residents of an effective clinical teacher.

    The aim of this qualitative study is to explore the perceived characteristics of an effective clinical teacher among medical students compared to residents graduating from an Asian medical school and whether there is a difference regarding cognitive and non-cognitive domain skills.

    II. METHODS

    A. Participants

    The participants consisted of final/fifth year medical students (M5s) from the Yong Loo Lin School of Medicine (YLLSoM), National University of Singapore (NUS) who were posted to the National University Hospital (NUH) to do their student internship posting in 2016. To ensure sufficient working experience, the National University Health System (NUHS) residents who had graduated from the YLLSoM and who had recently completed their intermediate specialty examinations were recruited. These were third to fifth year residents in different programmes. Maximal variation sampling of the M5s and the residents of both gender, different ethnic groups and from different specialties (for residents only) was done.

    B. Design

    A pragmatic qualitative research design (Savin-Baden & Howell Major, 2013) was used to get the participants to reflect on their own learning journey affecting their perceptions of the qualities that make an effective clinical teacher from the time they were first exposed to clinical medicine in year 3 (M3) of medical school to final year (M5) for the students, and to residency for the residents.

     C. Data Collection

    Semi-structured one-on-one interviews using open-ended questions were conducted. A list of M5s doing their student internship programme in the various departments in NUH was invited via an e-mail invitation to participate in this study. To ensure maximal variation sampling, M5s of both gender and as far as possible different ethnic groups were recruited. As for the residents, through the Graduate Medicine Education Office in NUH, residents of both gender, from different ethnic groups and different specialties (both procedural and non-procedural) were selected from those who responded voluntarily to the invitation to participate in this study to ensure maximal variation sampling as residents from procedural specialties may have different perceptions of effective clinical teachers from non-procedural specialties.

    Written consent after reading the Participant Information Sheet was taken from the interviewees before the interview was conducted in a quiet room. The interview was audiotaped and lasted between 30 and 45 minutes.

    D. Data Analysis

    The audiotaped interviews were transcribed. As all the 12 interviews were conducted by the principal investigator (PI) (SO) and although the coding and official analysis of the interviews were done after all the 12 interviews were transcribed, the PI had taken note of themes emerging and decided on ending the interviews after no substantial new themes had emerged.

    In the first phase, open coding, initial categories of the information on characteristics of effective clinical teachers by segmenting information and assigning open codes were formed. In the second coding phase, broader categories were developed through conceptually related ideas. The third phase involved selective coding where the individual categories were counterchecked with Sutkin et al.’s (2008) categories of teacher, physician and human characteristics and whether they were in the cognitive or non-cognitive domains (Table 1). Further related categories according to Sutkin et al.’s (2008) classification were brought together.

    Physician Characteristics

    P1

    Demonstrates medical/clinical knowledge

    P2

    Demonstrates clinical and technical skills/competence, clinical reasoning

    P3

    Shows enthusiasm for medicine

    P4

    A close doctor-patient relationship

    P5

    Exhibits professionalism

    P6

    Is scholarly (does research)

    P7

    Values teamwork and has collegial skills

    P8

    Is experienced

    P9

    Demonstrates skills in leadership and /or administration

    P10

    Accepts uncertainty in medicine

    P11

    Others

    Teacher Characteristics

    T1

    Maintains positive relationships with students and a supportive learning environment

    T2

    Demonstrates enthusiasm for teaching

    T3

    Is accessible/available to students

    T4

    Provides effective explanations, answers to questions, and demonstrations

    T5

    Provides feedback and formative assessment

    T6

    Is organized and communicates objectives

    T7

    Demonstrates knowledge of teaching skills, methods, principles, and their application

    T8

    Stimulates students’ interest in learning and/or subject

    T9

    Stimulates or inspires trainees’ thinking

    T10

    Encourages trainees’ active involvement in clinical work

    T11

    Provides individual attention to students

    T12

    Demonstrates commitment to improvement of teaching

    T13

    Actively involves students

    T14

    Demonstrates learner assessment/evaluation skills

    T15

    Uses questioning skills

    T16

    Stimulates trainees’ reflective practice and assessment

    T17

    Teaches professionalism

    T18

    Is dynamic, enthusiastic, and engaging

    T19

    Emphasizes observation

    T20

    Others

    Human Characteristics

    H1

    Communication skills

    H2

    Acts as role model

    H3

    Is an enthusiastic person

    H4

    Is personable

    H5

    Is compassionate/emphathetic

    H6

    Respect others

    H7

    Displays honesty

    H8

    Has wisdom, intelligence, common sense, and good judgement

    H9

    Appreciates culture and different cultural backgrounds

    H10

    Consider other’s perspectives

    H11

    Is patient

    H12

    Balances professional and personal life

    H13

    Is perceived as a virtuous person and a globally good person

    H14

    Maintains health, appearance, and hygiene

    H15

    Is modest and humble

    H16

    Has a good sense of humour

    H17

    Is responsible and conscientious

    H18

    Is imaginative

    H19

    Has self-insight, self-knowledge, and is reflective

    H20

    Is altruistic

    H21

    Others

    Note: Italics denotes cognitive characteristics; Bold denotes non-cognitive characteristics.

    Table 1. Classification of characteristics of outstanding clinical teachers (Sutkin et al., 2008)

    E. Trustworthiness

    To enhance the credibility of the research, member checking on the accuracy of interview transcription was done. The same transcription was coded by the PI (SO) and a co-researcher (CT) and the themes and differences were discussed and resolved together. The themes were then discussed with another co-researcher (JF) who is an outsider to the research setting. To contribute to the dependability of the data, a reflexivity diary was kept to reflect on the process and the PI’s role and influence on this study. This is because the PI is the person overall in charge of the residency training and has vast experience in teaching both undergraduate and postgraduate learners and has observed undergraduates seemingly valuing the willingness of time spent teaching in contrast to postgraduate learners who value effective teaching on the job. The PI emphasised to participants that whatever they mentioned in this study would not affect them in any way in their assessments, selection into a residency programme, job selection nor career progression. As a point of note, none of the interviewees mentioned any of the authors by name in the interviews when describing an effective clinical teacher.

     III. RESULTS

    A total of six final year medical students from the YLLSoM consisting of three males and three females with a mean age of 23 years old were interviewed. As for the residents group, they consisted of four males and two females. There were two internal medicine year 3 residents, one paediatric year 5 resident, one emergency medicine year 4 resident, one orthopaedic year 3 resident and one urology year 4 resident with a mean age of 29 years (range 26-33 years). All of them were of Chinese ethnicity.

    The characteristics of effective teachers were mapped onto Sutkin et al.’s (2008) review paper (Table 1) and while the majority of the characteristics could be mapped, those characteristics not able to be mapped would be considered as new characteristics. Referring to the summary of results in Table 2, the top characteristic identified equally by the medical students and residents group was approachability, in the non-cognitive domain. This was described as being “relatable, personable, forming good rapport, warm, able to remember students’ names, having a sense of humour, sharing personal experience”. Medical student 2 aptly described its importance: “Approachability in being willing to teach is an inborn trait. It acts as a screening tool. It opens the door for a student to decide whether or not this clinical tutor is someone she is likely to approach to learn from.” Interestingly, while both the medical students and residents group unanimously identified the need for a clinical teacher to have a threshold level of clinical competence, followed by a teacher who is warm and approachable with a passion to teach, this latter requirement was emphasised as particularly important in undergraduate teaching. In contrast, a postgraduate trainee/resident was able to accept a less warm but skillful clinician to learn advanced surgical skills from as they were more able to do self-directed learning being already in a training programme and they could observe and learn.

    Total

    MS

    R

    Characteristics

    Teacher

    Physician

    Human

    Cognitive

    Non-Cognitive

    10

    5

    5

    Approachability

    X (T3)

     

    X (H4)

     

    x

    9

    3

    6

    Passion/enthusiasm in teaching/engaging

    X  (T2)

     

     

     

    x

    8

    5

    3

    Provide effective explanations, answers to questions, and demonstrations (T4)

    Demonstrate clinical and technical skills/competence, clinical reasoning (P2)

    X (T4)

    X (P2)

     

    x

     

    7

    3

    4

    Creates conducive learning environment

    • patient (H11)
    • humble (H15)
    • learning without fear/non-threatening,
    • open to suggestions/questions

    X (T1)

     

    X (H11, H15)

     

    x

    7

    3

    4

    Role modeling

    • Learn art of Medicine
    • Patient interaction, shows respect (H6)
    • Shows by example
    • Communication (H1)

    x

    x

    X (H1, H6)

     

    x

    7

    2

    5

    Teach at appropriate level/know learning objectives

    X (T6)

     

     

    x

     

    7

    3

    4

    Sacrifice time

    x

     

     

    x

     

    6

    3

    3

    Realistic/concrete learning

    X (T6)

     

     

    x

     

    6

    2

    4

    Feedback, supervision, assessment for learning

    X (T5, T19)

     

     

    x

     

    5

    2

    3

    Knowledgeable/up to date/evidence-based

     

    X (P1)

     

    x

     

    5

    4

    1

    Exam-oriented

    x

     

     

    x

     

    4

    2

    2

    Inspirational to learning

    X (T8, T9, T18)

     

     

     

    x

    4

    1

    3

    Clinical thinking/Demonstrate to impart/pedagogy

    X (T9)

    X (P2)

     

    x

     

    3

    2

    1

    Nurturing/encouraging/compassion for students & team

    X (T11)

     

    X

     

    x

    2

    0

    2

    Allows hands-on/encourages trainees active involvement in clinical work

    X (T10)

     

     

     

    x

     

     

     

    Others: Strict, elocution, fair/moral compass (H13, H7), innovative (T12), directs learners, worldly-wise; empathy (H5), interpersonal skills, humour (H16)

     

     

     

     

     

    Note: (T), (P) and (H) refer to the specific Sutkin et al.’s (2008) classification as given in Table 1.

    Table 2. Characteristics of effective teachers identified by Medical Students (MS) and Residents (R) classified into teacher, physician and human characteristics and cognitive vs non-cognitive domains and mapped onto Sutkin et al.’s (2008) Classification (Table 1)

    The second most important characteristic identified was having a passion/enthusiasm in teaching, in the non-cognitive domain. This was described as “engaging, enthusiastic to help residents learn, enthusiasm/infectious attitude rubs off, lively, draws out from learners, takes time to explain to students”. Resident 5 explained: “Passion is actually demonstrated in the knowledge you display. Because when you are interested in something, you can go on to explore the depth.  People who display passion are able to depict the subject matter in a very interesting, personal and in a lively way. Passion is also about the desire to learn about things and to contribute to things. So in a sense teaching is not a passive tool for the diffusion of students … it’s also the ability to be able to draw things out from the students …draw contribution or ideas…”. Passion as a characteristic was mentioned by all the residents but not by all of the medical students.

    The third most important characteristic identified can be summarised as “providing effective explanations, answers to questions, and demonstrations” (a teacher characteristic) and “demonstrates clinical and technical skills/competence, clinical reasoning” (a physician characteristic) in the cognitive domain. This was described as “being able to break down concepts into digestible chunks; being able to synthesise and teach in understandable way; how to think, synthesise and use information; concise, targeted, clear thinking; headings, subheadings, elaborations; clarity in giving instructions and thought so that everyone is on the same page; demonstrate better way of presenting and more accurate way of physical examination”. This was identified more in the medical student group than in the resident group.

    Most of the other characteristics generally coincided with Sutkin et al.’s (2008) paper. Among the two cognitive domains skills were “teaching at appropriate level/knowing learning objectives” as well as being willing to “sacrifice time” demonstrating commitment for student education. The teachers who sacrificed their time gave additional teaching sessions and did not rush through. The medical students and the residents identified this characteristic as something they really valued in undergraduate teaching. Another characteristic in the cognitive domain was “Realistic/concrete learning” was described as “bedside teaching; teaching with practical aspect, case-based teaching; use of clinical pictures, electrocardiogram, clinical quiz and learning aids”. This form of learning was identified as being effective by both the medical students and residents equally. In contrast, “feedback, supervision, assessment for learning” described as “being able to discuss in detail as physically present; balance between supervision and resisting urge to take over in an operation; good feedback with balance of positive and negative points done in a fun and nice way” was identified more by the residents than the medical students group.

    Being “exam-oriented” i.e., the teacher being able to prepare the students well for exams, was notably a characteristic identified mainly by the medical students but was one not identified at all in Sutkin et al.’s (2008) paper nor other more recent references. To quote medical student 1, “I guess especially for medical students, it is whether this tutor prepares us well for the exams and in terms of meeting our academic objectives.”  Medical student 5: “He teaches us very exam focused and he synthesises all the information very succinctly for exams.”

    The medical students were specifically asked whether they identified a difference in the characteristics they valued in their teachers between when they were first introduced to clinical medicine in M3 compared to now in M5. The students almost unanimously expressed that in M3, as they had just been exposed to clinical medicine, they identified the need to build up their medical knowledge through more content-heavy didactic style of teaching that could be described as more of spoon-feeding than self-directed learning. Medical student 5 said, “Year 3 is more introductory kind of year so we don’t know anything. So what a good tutor to me in year 3 was whoever can teach me approaches, impart didactic teachings like knowledge.” They valued connections back to the basic sciences taught in their first two years of medical school and teachers who taught them how to approach patients. They were open to the gradual introduction of self-directed learning but it should not hold up the pace of the lesson if the students were unable to answer. In contrast, at the time of interview they were in M5 and they had two main aims. Their first aim was to look for good role-models for their upcoming internship and choice of residency for some. Hence, they appreciated bedside teaching with close supervision and feedback on medical knowledge applied to actual clinical care. Moreover, bedside examination skills and patient communications cannot be studied at home. At M5, they valued more self-directed learning as they were more equipped to search for information themselves unlike when they were in M3. They also greatly valued preparation for their final exams which would involve clinical examination in the form of Objective Structured Clinical Examination. In this aspect, they valued teachers who could teach them clinical reasoning on how to synthesise information to be applied to management of actual patients. The second aim had become more important as their final exams drew near. This feedback was also expressed by the residents when they recalled on what they looked for in their undergraduate years.

    For the residents who were in their third year of their residency and beyond, they identified the need for more active, self-directed learning. They mentioned the need to ask the ‘why questions’ and to learn evidence-based clinical practice. They appreciated experienced tutors who shared pearls and personal experience with them. They preferred to learn from good teachings during ward rounds and clinics and mentioned that didactic teaching was less important unlike in their undergraduate days and also as a first year resident where they still appreciated more spoon-feeding. As a more senior resident, they found discussions, greater analysis, asking questions to identify knowledge gaps, opportunity to present and testing useful because they already had a fund of medical knowledge.

     IV. DISCUSSION

    The results of this study suggest that there are differences in the perceived characteristics of an effective clinical teacher among medical students compared to residents. The results support Jonassen’s theory of constructivism (1991) as seen by the medical students at the beginning of their clinical year (M3) wanting more didactic teaching to ‘spoon-feed’ them with medical knowledge. As these students move on to become more senior in M5, and then residency, they start appreciating teachers who help them become more self-directed learners. These more senior learners also value feedback to help them deal with more complex ill-defined problems that they encounter during their daily clinical work. This is supported by more residents than medical students identifying feedback and supervision as well as clinical decision making/thinking as important characteristics of an effective clinical teacher (Table 2).

    It is also interesting to note that the top two characteristics of approachability and passion/enthusiasm in teaching are both in the non-cognitive domains. In fact, they are probably fundamental attributes that make a good teacher into a great one as they lead to a lot of teaching experience coupled with feedback from the learners that make them become good at simplifying and explaining concepts well, especially in undergraduate teaching. For the students beyond a baseline clinical competence, they value clinical teachers who want to teach rather than those who may be excellent top clinicians who do not possess the soft skills and the approachability for the students to want to have the courage to learn effectively from him/her. In contrast, the residents are willing to accept less ‘warm’ teachers if they are able to learn advanced clinical skills from them, particularly in the procedural specialties.

    One of the characteristics that has not been identified in any of the references, including Sutkin et al.’s (2008) review paper is that of being exam-oriented. This was a characteristic identified by four of the medical students but only by one of the residents who mentioned it while recalling his undergraduate days. This is not too surprising because Frambach et al. (2012) have found that Asian students tend to strive for success and to rank among the top achievers in an examination. The fact that the YLLSoM is Asia’s leading medical school (QS Top Universities, 2015; Times Higher Education, 2015) and hence the crème de la crème of Singapore’s students study at YLLSoM as seen by both the 10th and 90th percentiles of Medical students getting all A grades in their Singapore-Cambridge GCE A-level admission scores (National University of Singapore, 2019) can explain the exam-orientedness of the students. Moreover, Singapore practices meritocracy (Prime Minister’s Office, 2015) and in a small country of only 719.1 km² with a population of 5.35 million (World Bank, 2015) with only three public healthcare clusters, doing well in exams is seen as a tried and tested way of securing a good future. Failing in a high-stakes exam such as the final Bachelor of Medicine and Bachelor of Surgery (MBBS) exams will delay one’s progression to the next stage of one’s career such as admission to a residency training programme, and in a small country like Singapore where it is perceived to have few opportunities of starting afresh, it is not surprising that so much emphasis is placed on doing well in exams and a teacher who is able to prepare students well for exams is greatly valued.

    There are several limitations to this study. Although we had wanted to recruit interviewees from different ethnicity, all 12 who responded to our invitation were Chinese, though participating in a multi-cultural and multi-ethnic public school. Another limitation is that this study only explores the perceptions of the learners themselves. It will be more balanced if the viewpoints of the teachers are obtained as well.

    V. CONCLUSION

    This study suggests that there are differences in the perceptions of an effective clinical teacher between medical students compared to residents. Medical students valued a more didactic spoon-feeding type of teacher in their earlier clinical years. However, final year medical students and residents valued feedback and role-modelling at clinical practice. The top two characteristics of approachability and passion for teaching are in the non-cognitive domains. The results of this study will help to inform educators of the differences in a learner’s needs at different stages of their clinical development and to potentially adapt their teaching styles.  In addition, it is also possible for certain non-cognitive domain skills to be developed through recognition of clinical teachers who are role models in showing by example the art of the practice of Medicine and being able to create a conducive non-threatening learning environment. There are definitely faculty development programmes which target at how to develop a conducive learning environment.

    Notes on Contributors

    Shirley Ooi, MBBS(S’pore), FRCSEd(A&E), MHPE(Maastricht) is senior consultant emergency physician at NUH and associate professor at NUS. She was the Designated Institutional Official NUHS Residency programme at the time of the study. Currently she is the Associate Dean at NUH. This study was her MHPE thesis. She reviewed the literature, designed the study, conducted the interviews, analysed the transcripts and wrote the manuscript.

    Clement Tan, MBBS(S’pore), FRCSEd (Ophth), MHPE(Maastricht), is associate professor, senior consultant and head of the Department of Ophthalmology, NUS and NUH. He was the first author’s local MHPE thesis supervisor. He co-analysed the transcripts and approved the final versions of the manuscripts.  

    Janneke M. Frambach PhD is assistant professor at the School of Health Professions Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, the Netherlands. She was the first author’s MHPE thesis supervisor. She supervised the study from the beginning to the final stage of manuscript writing with its revisions.

    Ethical Approval

    This study was reviewed and approved by the NUS Institutional Review Board (approval no. 3172), which considered the letter of invitation for recruitment of participants, participant information sheet, written informed consent for the audio-recordings of the one-on-one interviews, interview guide and confidentiality of participants.

    Acknowledgements

    The authors would like to thank the following for their help, advice and support, without which this study would not have been possible:

    • Medical student, Gerald Tan, for his help in transcribing many of the interviews.
    • The six YLLSoM medical students who had willingly come forward to be interviewed for this study.
    • The six NUHS residents who had willingly spared their time to be interviewed for this study.

    Funding

    No grant nor external funding was received for this study.

    Declaration of Interest

    The PI as the interviewer emphasised to the participants that whatever they mentioned in this study would not affect them in any way in their assessments, selection into a residency programme, job selection nor career progression. Moreover, their participation was entirely voluntary. The other two authors had no conflict of interest.

    References

    Bednar, A. K., Cunningham, D., Duffy, T. M., & Perry, J. D. (1991). Theory into practice: How do we link? In G.J. Anglin (Ed.), Instructional Technology: Past, Present, and Future. Englewood, CO: Libraries Unlimited.

    Branch, W. T., Osterberg, L., & Weil, R. (2015). The highly influential teacher: Recognising our unsung heroes. Medical Education, 49, 1121-27.

    Ciraj, A., Abraham, R., Pallath, V., Ramnarayan, K., Kamath, A., & Kamath, R. (2013). Exploring attributes of effective teachers-student perspectives from an Indian medical school. South-East Asian Journal of Medical Education, 7(1), 8-13.

    Elzubeir, M. A., & Rizk, D. E. E. (2001). Identifying characteristics that students, interns and residents look for in their role models. Medical Education, 35, 272-277.

    Frambach, J. M., Driessen, E. W., Chan, L. C., & van der Vleuten, C. P. M. (2012). Rethinking the globalization of problem-based learning: How culture challenges self-directed learning. Medical Education, 46, 738-747.

    Haider, S. I., Snead, D. R., & Bari, M. F. (2016). Medical students’ perceptions of clinical teachers as role model. PloS ONE, 11(3): e0150478. https://doi:10.1371/journal.pone.0150478

    Hatem, C. J., Searle, N. S., Gunderman, R., Krane, N. K., Perkowski, L., Schutze, G. E., & Steinert, Y. (2011). The educational attributes and responsibilities of effective medical educators. Academic Medicine, 86(4), 474-480.

    Hillard, R. I. (1990). The good and effective teacher as perceived by paediatric residents and faculty. American Journal of Diseases of Childhood, 144, 1106 –1110.

    Jacobs, J.  L., & Samarasekera, D. D. (2012). How we put into practice the principles of embedding medical students into healthcare teams. Medical Teacher, 34, 1008-1011.

    Jonassen, D. H. (1991). Evaluating constructivistic learning. Educational Technology, 31(9), 28-33.

    Kernan, W. N., Lee, M. Y., Stone, S. L., Freudigman, K. A., & O’Connor, P. G. (2000). Effective teaching for preceptors of ambulatory care: A survey of medical students. American Journal of Medicine, 108(6), 499-502.

    Kikukawa, M., Nabeta, H., Ono, M., Emura, S., Oda, Y., Koizumi, S., & Sakemi, T. (2013). The characteristics of a good clinical teacher as perceived by resident physicians in Japan: A qualitative study. BMC Medical Education, 13(1), 100.

    Kua, E. H., Voon, F., Tan, C. H., & Goh, L. G. (2006). What makes an effective medical teacher? Perceptions of medical students. Medical Teacher, 28(8), 738-741. 

    Low, M. J. W., Khoo, K. S. M., Kuan, W. S., & Ooi, S. B. S. (2020). Cross-sectional study of perceptions of qualities of a good medical teacher among medical students from first to final year. Singapore Medical Journal, 61(1), 28-33. 

    Mohan, N., & Chia, Y. Y. (2017). Our first steps into surgery: The role of inspiring teachers. The Asia-Pacific Scholar, 2(1), 29-30. https://doi.org/10.29060/TAPS.2017-2-1/PV1027

    National University of Singapore. (2019). National University of Singapore Undergraduate Programmes Indicative Grade Profile. Retrieved from http://www.nus.edu.sg/oam/gradeprofile/sprogramme-igp.html

    Nishiya, K., Sekiguchi, S., Yoshimura, H., Takamura, A., Wada, H., Konishi, E., Saiki, T., Tsunekawa, K., Fujisaki, K., & Suzuki, Y. (2019). Good clinical teachers in Paediatrics: The perspective of paediatricians in Japan. Paediatrics International, 62(5), 549-555.

    Prime Minister’s Office. (2010, May 5). “Old and new citizens get equal chance,” says MM Lee. [Press release].

    Paukert, J. L., & Richards, B. F. (2000). How medical students and residents describe the roles and characteristics of their influential clinical teachers. Academic Medicine, 75, 843-845.

    QS Top Universities. (2015) QS World University Rankings 2015-20116. Retrieved from: https://www.topuniversities.com/university-rankings/world-university-rankings/2015

    Savin-Baden, M., & Howell Major, C. (2013). Pragmatic qualitative research. In M. Savin-Baden & C. H. Major (Eds). Qualitative Research. The Essential Guide to Theory and Practice. London: Routledge. 

    Schiffer, R. B., Rao, S. M., & Fogel, B. S. (2003). Neuropsychiatry: A Comprehensive Textbook (2nd ed.). Philadelphia, PA: Lippincott Williams and Wilkins. 

    Searle, N. S., Hatem, C. J., Perkowski, L., & Wilkerson, L. (2006). Why invest in an educational fellowship program? Academic Medicine, 81, 936-940.

    Singh, S., Pai, D. R., Sinha, N. K., Kaur, A., Soe, H. H. K., & Barua, A. (2013). Qualities of an effective teacher: What do medical teachers think? BMC Medical Education, 13(128), 1-7.

    Sutkin, G., Wagner, E., Harris, I., & Schiffer, R. (2008). What makes a good clinical teacher in Medicine? A review of the literature. Academic Medicine, 83(5), 452-466.

    Times Higher Education. (2015). The World University Rankings 2015-16. Retrieved from: https://www.timeshighereducation.com/student/news/best-universities-world-revealed-world-university-rankings-2015-2016

    Venkataramani, P., Krishnaswamy, N., Sugathan, S., Sadanandan, T., Sidhu, M., & Gnanasekaran, A. (2016). Attributes expected of a medical teacher by Malaysian medical students from a private medical school. South-East Asian Journal of Medical Education, 10(2), 39-45.

    White, J. A., & Anderson, P. (1995). Learning by internal medicine residents: Differences and similarities of perceptions by residents and faculty. Journal of General Internal Medicine, 10, 126-132.

    World Bank. (2015). Annual Report 2015. Retrieved from: https://www.worldbank.org/en/about/annual-report-2015

    *Shirley Ooi
    Emergency Medicine Department,
    National University Hospital
    9 Lower Kent Ridge Road, Level 4,
    National University Centre for Oral Health Building,
    Singapore 119085
    Tel: (65)6772-2458
    Fax: (65)6775-8551
    Email: shirley_ooi@nuhs.edu.sg

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