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Background: The definition of feedback in clinical education has shifted from information delivery to student-teacher dialogue. However, based on Hofstede's theory, countries with large power distance or a robust social hierarchy and collectivistic cultural dimensions can reduce the feedback dialogue to a minimum. Indonesia is classified in this group, with some Asian, African, Mediterranean, and Latin American countries. This study explores the interactional communication of feedback during clinical education in a hierarchical and collectivistic context. Methods: The focused ethnographic approach was applied to the clinical rotation program in an Indonesian teaching hospital. Data sources included observations of feedback episodes during workplace-based assessments followed by interviews with clinical supervisors and students. The data were compiled within 16 weeks of observation in 7 groups of clinical departments, consisting of 28 field notes, audiotaped interviews including nine focus group discussions of students (N = 42), and seven in-depth interviews with clinical supervisors. Data were analyzed through transcription, coding, categorization, and thematic analysis using the symbolic interactionist perspective. Results: We identified four themes representing actual interactional communication and its 'meaning' or interpretation. The interactional communication in feedback is described in the first and second themes, such as 1) Students play the subordinate roles in a feedback dialogue; 2) The feedback content is focused on explanation and students' limitations. The third and fourth themes represent the clinical supervisors' and students' interpretation of their feedback experience, such as 3) Clinical supervisors' perspectives are mostly on dissatisfaction and teaching authority; 4) Students' acceptance of reality and negative affection. Conclusions: This study shows that the social gap between students and clinical supervisors in Indonesia, and other countries in the same cultural classification, potentially causes communication barriers in the feedback dialogue. The adaptation of 'feedback as a dialogue' requires further effort and research to develop communication strategies in feedback that consider the national culture and context.
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BACKGROUNDS: Research concerning student-centered learning (SCL) recommends a comprehensive assessment of medical students' competencies including their personal and professional characters. Accordingly, nurturing future doctors should be in a continuous mentorship program. However, in a hierarchical culture, communication is one-way with limited feedback and reflection. We aimed to explore challenges and opportunities for SCL implementation in medical schools in this cultural setting necessary for a globally interdependent world. METHODS: Two cycles of participatory action research (PAR) were conducted, involving medical students and teachers in Indonesia. A national conference on SCL principles was conducted between the cycles, also the SCL modules were developed for each institution and feedback was shared. Twelve focus group discussions were conducted (before and after the module development), with 37 medical teachers and 48 medical students from 7 faculties of medicine across Indonesia at various levels accreditation. Following verbatim transcriptions, a thematic analysis was conducted. RESULTS AND DISCUSSIONS: In cycle 1 PAR, some challenges in implementing SCL were identified: lack of constructive feedback, overloaded content, summative-based assessment, hierarchical culture environment, and teachers' dilemma of committed time between patient-care and education. In cycle 2, several opportunities to approach the SCL were proposed: a faculty development program on mentorship, students' reflection guides and training, a more longitudinal assessment system, also a more supportive government policy on the human resources system. CONCLUSIONS: The main challenge of fostering student-centered learning revealed in this study was a teacher-centered learning tendency in the medical curriculum. The weighting towards summative assessment and the national educational policy drive the curriculum like a 'domino effect', away from the expected student-centered learning principles. However, using a participative method, students and teachers could identify opportunities and articulate their educational needs, i.e., a partnership-mentorship program, as a significant step toward student-centered learning in this cultural context.
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Students, Medical , Humans , Educational Status , Curriculum , Faculty , Health Services ResearchABSTRACT
INTRODUCTION: Indonesia is a huge country consisting of 33 provinces with different characteristics. There are 83 medical schools across Indonesia with different accreditation statuses. The Indonesia Medical Doctor National Competency Examination (IMDNCE) has been established to control the quality of medical school graduates. The implementation of IMDNCE needed to be evaluated to determine its impact. To date, there has not been any research in Indonesia that explores the stakeholders' perceptions toward IMDNCE. This study aimed to explore how the stakeholders in Indonesia perceived the impact of IMDNCE towards performances of medical school graduates in clinical practice. METHODS AND STUDY PARTICIPANTS: A qualitative study with phenomenological approach was conducted to investigate perceptions of stakeholders including representatives from consumer organizations, the National Health Coverage, the Ministry of Health, the Indonesian Medical Association, employers (hospital and health center directors), clinical supervisors as well as patients across Indonesia. Data were obtained through focus group discussions (FGDs) and interviews. The study used thematic analysis methods to obtain the results. RESULTS: A total of 90 study participants participated in the study including 10 representatives of consumer watchdog organizations, the National Health Coverage, the Ministry of Health, the Indonesian Medical Association, 31 employers, 32 professionals, and 17 patients. The study found three general themes which represent the perceptions of the stakeholders towards performances of medical school graduates in clinical practice: IMDNCE as an effort to standardize doctor graduates in Indonesia, the results of IMDNCE as a mean to reflect the quality of medical education in Indonesia, and IMDNCE as an effort to improve health services in Indonesia through the quality of graduates. CONCLUSION: In general, the stakeholders perceived that the IMDNCE was able to standardize medical school graduates from various medical schools across Indonesia. However, the IMDNCE needs to be further developed to maximize its potential in improving the competences of Indonesian medical students.
