Applying narrative medicine to prepare empathetic healthcare providers in undergraduate pharmacy education in Singapore: a mixed methods study.

BACKGROUND: Narrative medicine demonstrated positive impact on empathy in medicine and nursing students. However, this pedagogical approach had not been evaluated in pharmacy education. This study sought to apply and evaluate the narrative medicine approach in extending empathy in Asian undergraduate pharmacy students. METHODS: Narrative medicine was applied through workshops which used narratives of people with different experiences and perspectives. First-year undergraduate pharmacy students who volunteered and attended these workshops formed the intervention group (N = 31) and the remaining first-year cohort formed the control group (N = 112). A sequential explanatory mixed methods approach was adopted in which quantitative methods were first used to measure impact on pharmacy students' empathy using the Jefferson Scale of Empathy- Health Professions Student (JSE-HPS), and qualitative methods (i.e. group interviews) were then used to assess pharmacy students' emotional responses to narratives, and the perspectives of pharmacy students and faculty of this pedagogical approach. RESULTS: There was no difference in JSE-HPS scores between intervention and control groups across baseline (i.e. upon matriculation), pre-intervention, and post-intervention timepoints. Pharmacy students in the intervention group had lower scores in Factor 3 ("Standing in People's Shoes") following the intervention. Five themes, guided by internal and external factors in cognition, emerged from the Group Interviews: (1) incongruence between students' motivation and faculty's perception, (2) learning context, (3) academic context, (4) cognitive system, and (5) affective system. Themes 1, 4 and 5 referred to internal factors such as students' motivation, perceived learnings, and feelings. Themes 2 and 3 referred to external factors including workshop materials, activities, content, and facilitation. CONCLUSION: This study is the first to demonstrate that pharmacy students engaged with the narrative medicine approach as narratives elicited emotional responses, exposed them to diverse perspectives, and deepened their appreciation of the importance of empathy and complexities of understanding patients' perspectives. Scaffolded educational interventions using narratives and real-life patient encounters, alongside longitudinal measurements of empathy, are necessary to bring about meaningful and sustained improvements in empathy.

Empathy in health professions education: What works, gaps and areas for improvement.

INTRODUCTION: Developing a physician equipped with both technical and affective skills is crucial in ensuring quality patient care. Of these skills, nurturing empathy is a key skill that has been studied in great detail, particularly among medical undergraduates. Despite numerous studies trending the changes in empathy, the results are often contradictory or confusing. Our study aims to find what interventions are effective to inculcate empathy in both undergraduate and postgraduate medical education and suggest areas for improvement. METHODS: A narrative review was conducted on the interventions in nurturing empathy in undergraduate and postgraduate medical education. Original research articles and systematic reviews with clear interventions and outcomes were included in the study. RESULTS: A total of 44 articles were reviewed. About 44% (n = 18) of the studies used a mixture of different approaches as their interventions. Some interventions were anchored by specific topics: Seven papers focusing on communication skills, three papers on humanities, and three on arts. A majority of the interventions (60%; n = 26) were implemented over a span of time as compared to studies which suggested a one-off intervention (30%; n = 12). Of the 26 papers in which the interventions were enforced over a period of time, 62% (n = 16) indicated an increase in student empathy whereas 16% (n = 4) indicated no changes in empathy post-intervention. On the contrary, 50% (n = 6) of the one-off interventions revealed no significant change in student empathy. Jefferson Scale of Empathy (JSE) is widely used in measuring student empathy postintervention, but approximately 41% of the studies included measuring tools other than JSE. CONCLUSIONS: Pedagogical methods that invoke thought processes related to the affective domain of learning and experiential learning are more effective than the didactic methods of teaching and learning. Multimodal mixed-methods approach that combine different pedagogical interventions is more likely to bring about the desired results.

Development of student empathy during medical education: changes and the influence of context and training.

PURPOSE: Empathy levels have been observed to often decrease when medical undergraduates move to the clinical years, particularly in the Western countries. However, empathy either remains similar or increases in many Asian medical schools. This study investigated the longitudinal empathy profile of medical students in Singapore. METHODS: Two cohorts of medical students who enrolled in 2013 and 2014 to the National University of Singapore were tracked for 5 years. The Jefferson Scale of Empathy-student version was used. Analyses on the mean of the empathy level and individual factors, year-wise and gender comparison were conducted. RESULTS: Average response rates for cohort 1 and 2 were 68.1% (n=181-263) and 55.4% (n=81-265), respectively. For both cohorts, there was no significant change across year of study in the mean empathy score. Average scores for both cohorts were 113.94 and 115.66. Though not significant, we observed mean empathy to be lowest at the end of year 5 (112.74) and highest in year 2 (114.72) for cohort 1 while for cohort 2, the lowest level of empathy was observed in year 5 (114.20) and highest in year 4 (118.42). Analysis of subcomponents of empathy only showed a significant difference for cohort one factor 1 (perspective taking) and factor 3 (standing in patients' shoes) across the study years. CONCLUSION: No significant change in empathy score was observed during the transition from pre-clinical to clinical years, unlike many Western and Far-Eastern studies. This might be due to the curriculum and influence of the Asian values.

Mobile learning in clinical settings: unveiling the paradox.

PURPOSE: The use of mobile devices among medical students and residents to access online material in real-time has become more prevalent. Most literature focused on the technical/functional aspects of mobile use. This study, on the other hands, explored students, doctors and patients' preferences and reasons towards the use of mobile devices in clinical settings underpinned by the Technology Acceptance Model 2 (TAM 2). METHODS: This research employs an exploratory research design using survey and semi-structured interviews. An online survey was administered to clinical year medical students, followed by semi-structured interviews with the doctors and patients. Questions for the online survey and semi-structured interviews were derived from previous literature and was then reviewed by authors and an expert panel. A convenience sampling was used to invite voluntary participants. RESULTS: Survey findings showed that most medical students used their devices to find drug information and practice guidelines. The majority of the students accessed UpToDate followed by Google to access medical resources. Key barriers that students often encountered during the use of mobile devices were internet connectivity in the clinical settings, reliability of the information, and technical issues. Thematic analysis of the interviews revealed four themes: general usage by students, receptivity of the use of mobile devices by students, features in selecting resources for mobile learning, and limitation in the current use of mobile devices for learning. CONCLUSION: The findings from this study assist in recommending suitable material using mobile devices to enhance learning in the clinical environment and expand the TAM 2.

Learning during the pandemic: Perspectives of medical students in Singapore.

The COVID-19 pandemic has significantly disrupted medical education, particularly affecting clinical-year students. Educational institutions often had to halt, shorten or impose significant restrictions on their hospital rotations due to strict infection control and social-distancing guidelines implemented in tertiary healthcare institutions, as well as manpower and logistical constraints amid the pandemic. Thus, distance-based learning platforms such as online lectures and case-based teaching were increasingly adopted in place of bedside and face-to-face tutorials. While interactive virtual case-based discussions are generally useful in imparting clinical reasoning skills to medical students, they are unfortunately not able to fully replicate the experience of clerking, examining and managing real patients in the wards, which is a quintessential process towards building clinical acumen and attaining core clinical competencies. Therefore, for final year medical students who are preparing for their Bachelor of Medicine and Bachelor of Surgery (MBBS) examinations, many are naturally concerned by how learning in this "new normal" may affect their ability to make the transition to become competent junior doctors. As such, we seek to share our learning experiences as the first batch of medical students to have completed our entire final year of clinical education amid the COVID-19 pandemic, and offer 4 practical suggestions to future batches of students on how to adapt and optimise clinical learning under these circumstances: actively engaging in virtual learning, making the most of every clinical encounter, learning how to construct peer teaching/practice sessions, and maintaining physical and psychological well-being.

Teaching Medical Research to Medical Students: a Systematic Review.

PHENOMENON: Research literacy remains important for equipping clinicians with the analytical skills to tackle an ever-evolving medical landscape and maintain an evidence-based approach when treating patients. While the role of research in medical education has been justified and established, the nuances involving modes of instruction and relevant outcomes for students have yet to be analyzed. Institutions acknowledge an increasing need to dedicate time and resources towards educating medical undergraduates on research but have individually implemented different pedagogies over differing lengths of time. APPROACH: While individual studies have evaluated the efficacy of these curricula, the evaluations of educational methods and curriculum design have not been reviewed systematically. This study thereby aims to perform a systematic review of studies incorporating research into the undergraduate medical curriculum, to provide insights on various pedagogies utilized to educate medical students on research. FINDINGS: Studies predominantly described two major components of research curricula-(1) imparting basic research skills and the (2) longitudinal application of research skills. Studies were assessed according to the 4-level Kirkpatrick model for evaluation. Programs that spanned minimally an academic year had the greatest proportion of level 3 outcomes (50%). One study observed a level 4 outcome by assessing the post-intervention effects on participants. Studies primarily highlighted a shortage of time (53%), resulting in inadequate coverage of content. INSIGHTS: This study highlighted the value in long-term programs that support students in acquiring research skills, by providing appropriate mentors, resources, and guidance to facilitate their learning. The Dreyfus model of skill acquisition underscored the importance of tailoring educational interventions to allow students with varying experience to develop their skills. There is still room for further investigation of multiple factors such as duration of intervention, student voluntariness, and participants' prior research experience. Nevertheless, it stands that mentoring is a crucial aspect of curricula that has allowed studies to achieve level 3 Kirkpatrick outcomes and engender enduring changes in students. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-020-01183-w.

Impact of an aging simulation workshop with different debrief methods on the development of empathy in pharmacy undergraduates.

INTRODUCTION: This study aimed to investigate a workshop's impact on empathy development, compare potential differences in effects among different workshop debrief methods, and identify if any demographic factors predict empathy development. METHODS: Participants were first randomly divided to receive either a didactic lecture, a jigsaw approach, or a fishbowl approach for the debrief method. In their respective arms, participants experienced simulation stations followed by their assigned debrief. Of 167 year-two National University of Singapore pharmacy undergraduates, 130 participated in the study and completed the Jefferson Scale of Empathy-Health Professions Student (JSE-HPS) version before and after the workshop. RESULTS: The JSE-HPS scores were significantly increased post-workshop; however, no significant differences in pre-post workshop score changes were observed among the three approaches. Overall, no demographic factor was identified to have significantly influenced empathy development. CONCLUSIONS: The study demonstrated that the simulation workshop developed empathy among pharmacy students regardless of the debrief method employed within the workshop. Future work would be necessary to assess if there are long-term impacts of different debrief methods on empathy development.

Admission policies and methods at crossroads: a review of medical school admission policies and methods in seven Asian countries.

Selecting the right applicants is an important part of medical student admission. While one universally accepted selection criterion is academic capacity, there are other criteria such as communication skills and local criteria (e.g., socio-cultural values) that are no less important. This article reviews the policies and methods of selection to medical schools in seven countries with varying socio-economic conditions and healthcare systems. Senior academics involved in medical education in Indonesia, Japan, Malaysia, the Philippines, Singapore, Sri Lanka, and Taiwan completed a pre-agreed pro-forma per each country to describe the country's admission policies and methods. The details were then compared and contrasted. This review identifies tension between many of the policies and methods used in medical school admissions, such as between the need to assess non-cognitive abilities and widen access, and between the need for more medical professionals and the requirement to set high entry standards. Finding the right balance requires careful consideration of all variables, including the country's human resource needs; socio-economic status; graduates' expected competencies; and the school's vision, mission, and availability of resources.

Faculty development in medical education: an environmental scan in countries within the Asia pacific region.

PURPOSE: In recent years, faculty development (FD) research is more noticeable within an inter-professional context and in allied health education. However, there is a paucity of published literature on FD medical education programs in Asia. With the formation of the Asia Pacific Medical Education Network (APME-Net) in 2015, a scoping review of an environmental scan of FD medical education programs in main institutions in South East Asia and Australia in 2018 was conducted. METHODS: A survey was developed to collect data on FD in medical education after several rounds of discussion with APME-Net members. The representatives from nine countries in Asia and Australia were invited to partner in this research project. They sent the questionnaire to the Dean of all different medical schools after ethical clearance. The data collected was analyzed using descriptive statistics. RESULTS: Only institutions in four countries responded to the questionnaire. The medical/health professions education center/department/unit has been established in most educational institutions in these countries. These centers/departments/units mostly carry out FD programs to improve the teaching and learning skills of trained participants, particularly clinical teachers via workshops and seminars. Staffing issues and participant buy-in are the current key priorities of the center/department/unit in terms of FD. Lastly, research related FD program has not been well-supported in these countries, hence, the lack of publication in this area. CONCLUSION: Collaboration between countries to address key areas of interest and develop more standardized and productive FD medical education is required especially in research.

Response and Lessons Learnt Managing the COVID-19 Crisis by School of Medicine, National University of Singapore.

This article was migrated. The article was marked as recommended. Background: Healthcare professionals are playing an important role in the recent COVID-19 outbreak. It is crucial that the health systems maintain their ability to train students and residents during this time. However, there is a paucity of literature on the measures taken by higher education institutions to ensure academic continuity. The aim of this article is to share the systematic measures that were taken during the COVID-19 pandemic by Yong Loo Lin School of Medicine, National University of Singapore. Methods: We discussed our multi-faceted approach to protect students, staff and patients/ standardized patients during the COVID-19 outbreak that occurred during a pivotal time in the school's academic calendar. Results: Our approach to ensuring academic continuity and quality were based on best practices in the following areas: 1) A coordinated leadership and management process 2) Prioritising safety for all stakeholders 3) Dissemination of information amongst the stakeholders in a transparent and efficient way, and 4) Maintaining the rigour and quality of training. Conclusion: The initiatives were implemented as we leveraged on the available infrastructure and the collective team efforts of all involved. Further research will be done to evaluate the usefulness of these measures. We hope that this article would be a useful reference for other schools as they evaluate their pandemic preparedness in the event that the COVID-19 outbreak affects their country or similar crisis event in the future.

Exploring the Cultivation of Self-Regulated Learning (SRL) Strategies Among Pre-Clinical Medical Students in Two Medical Schools.

PURPOSE: Research has shown that many undergraduate students struggle with self-regulated learning (SRL) in clinical year as they are insufficiently supported by the staff in the early year to prepare them for the transition. Hence, this study aims to find out the SRL strategies and the approaches that could promote SRL among pre-clinical students in two medical schools. METHOD: This is a mixed-method study. The Motivated Strategies for Learning Questionnaire (MSLQ) was used to collect student SRL strategies while semi-structured interviews with faculty members and focus group discussions with students were used to gather data on the approaches that promote SRL. Student MSLQ was analysed using descriptive statistics while interviews were transcribed verbatim and thematically analysed. RESULTS: A pilot using MSLQ with 413 students recorded a Cronbach's alpha of 0.928 for the questionnaire. The actual study involved 457 Years 1 & 2 students. Students from both institutions are motivated by the Task Value, and they use Elaboration and Organisation strategies the most in their pre-clinical year. Three themes emerged from the qualitative analysis of this study: characteristics of strategies that promote SRL, hindrance in promoting SRL, and opportunities in promoting SRL. CONCLUSIONS: Our findings indicate that students' intrinsic motivation is generally high in pre-clinical year. However, metacognition and critical thinking strategies will need to be enhanced among students. Despite knowing teaching and learning approaches could promote these strategies, many teachers are still not confident in doing so and hence training dang sharing best practices might be helpful in promoting SRL.

Improving a newly adapted teaching and learning approach: Collaborative Learning Cases using an action research.

PURPOSE: Although medical curricula are now better structured for integration of biomedical sciences and clinical training, most teaching and learning activities still follow the older teacher-centric discipline-specific formats. A newer pedagogical approach, known as Collaborative Learning Cases (CLCs), was adopted in the medical school to facilitate integration and collaborative learning. Before incorporating CLCs into the curriculum of year 1 students, two pilot runs using the action research method was carried out to improve the design of CLCs. METHODS: We employed the four-phase Kemmis and McTaggart's action research spiral in two cycles to improve the design of CLCs. A class of 300 first-year medical students (for both cycles), 11 tutors (first cycle), and 16 tutors (second cycle) were involved in this research. Data was collected using the 5-points Likert scale survey, open-ended questionnaire, and observation. RESULTS: From the data collected, we learned that more effort was required to train the tutors to understand the principles of CLCs and their role in the CLCs sessions. Although action research enables the faculty to improve the design of CLCs, finding the right technology tools to support collaboration and enhance learning during the CLCs remains a challenge. CONCLUSION: The two cycles of action research was effective in helping us design a better learning environment during the CLCs by clarifying tutors' roles, improving group and time management, and meaningful use of technology.

The clarion call for a third wave in medical education to optimise healthcare in the twenty-first century.

During the years preceding 1910, the education and training of physicians (doctors) -to-be was based mainly on a master-apprentice model; the primary focus then was on the teaching and development of clinical skills. In 1910, however, Abraham Flexner submitted a highly influential report to the American medical authorities: in it, he recommended that all medical schools should be university-based and that, importantly, medical practice should have a scientific basis strongly underpinned by the basic medical sciences. The recommendation provided the impetus for the design of medical education that begins with a pre-clinical phase to provide the strong scientific foundation for the clinical phase that follows. During the clinical phase, student learning will focus primarily on the clinical sciences relating to the diagnosis, treatment and management of patient care. Thus, two key 'pillars' (the basic sciences and the clinical sciences) of medical education were established; this two pillar model of medical education persisted for many decades thereafter and remained so till today. However, in order to optimise delivery of health care this must be viewed as an 'eco-system' taking into account the practice setting both present and future. The authors will attempt to provide a background to the changing trends in medical education and the changing practice environment, due primarily to the disruptive forces of change in this article.

Impact of faculty development programs for positive behavioural changes among teachers: a case study.

PURPOSE: Faculty development (FD) is essential to prepare faculty members to become effective teachers to meet the challenges in medical education. Despite the growth of FD programmes, most evaluations were often conducted using short questionnaires to assess participants' satisfaction immediately after they attended a programme. Consequently, there were calls for more rigorous evaluations based on observed changes in participants' behaviours. Hence, this study aims to explore how the FD workshops run by the Centre for Medical Education, Yong Loo Lin School of Medicine, National University of Singapore have impacted behavioural changes in the educators. METHODS: We followed up with the educators at least half a year after they have attended the workshops. With limited literature as reference, we initiated a small-scale case-study research design involving semi-structured interviews with six educators which was triangulated with three focus group discussions with their students. This allowed us to explore behavioural changes among the educators as well as evaluate the feasibility of this research methodology. RESULTS: We identified three emerging categories among the educators: ignorance to awareness, from intuition to confirmation and expansion, and from individualism to community of practice. CONCLUSION: Although FD have placed much emphasis on teaching and learning approaches, we found that the teacher-student interaction or human character components (passionate, willing to sacrifice, are open to feedback) in becoming a good educator are lacking in our FD workshops.

Has medical education killed "silence"?

There is an ignorance of "silence" observed from student selection methods to teaching and learning approaches. While selecting the candidates with suitable values to medical schools is crucial, most methods are unable to address fairness issue toward students from some disadvantaged background or certain personality specifically introversion. Similarly, teaching and learning approaches have shifted away from didactic to a more discursive methods such as brainstorming, team-based learning and case-based learning. These methods emphasize active participation and communication with team members, but having more discussion does not indicate that deep learning has taken place. Majority of these approaches require students to complete a task within an allocated time frame. Therefore, most of the time is utilized to complete a task instead of learning how to acquire a skill or learning how to learn. Important "silent" skills such as observation, reasoning process, and listening skills, are given less time or almost none due to time constraint within these discursive approaches, although these skills are extremely important as a doctor. Hence, it is time to think about on how best to balance the use of silence and externalize thought processes in medical education.

Complex and novel determinants of empathy change in medical students.

PURPOSE: Physician empathy is a core attribute in medical professionals, giving better patient outcomes. Medical school is an opportune time for building empathetic foundations. This study explores empathy change and focuses on contributory factors. METHODS: We conducted a cross-sectional study involving 881 students (63%) from Years 1 to 5 in a Singaporean medical school using the Jefferson Scale of Physician Empathy-Student version (JSPE-S) and a questionnaire investigating the relationship between reported and novel personal-social empathy determinants. RESULTS: Empathy declined significantly between preclinical and clinical years. Female and medical specialty interest respondents had higher scores than their counterparts. Despite strong internal consistency, factor analysis suggested that the JSPE model is not a perfect fit. Year 1 students had highest Perspective Taking scores and Year 2 students had highest Compassionate Care scores. High workload and inappropriate learning environments were the most relevant stressors. Time spent with family, arts, and community service correlated with higher empathy scores, whilst time spent with significant others and individual leisure correlated with lower scores. Thematic analysis revealed that the most common self-reported determinants were exposure to activity (community service) or socialisation, personal and family-related event as well as environment (high work-load). CONCLUSION: While the empathy construct in multicultural Singapore is congruent with a Western model, important differences remain. A more subtle understanding of the heterogeneity of the medical student experience is important. A greater breadth of determinants of empathy, such as engagement in arts-related activities should be considered.

Conceptualizing workplace based assessment in Singapore: Undergraduate Mini-Clinical Evaluation Exercise experiences of students and teachers.

OBJECTIVES: The Mini-Clinical Evaluation Exercise (mini-CEX) is one of the most commonly used clinical assessment tools to provide learner feedback to drive learning. High quality constructive feedback promotes development and improves clinical competency. However, the effectiveness of feedback has not been objectively evaluated from the learners' and assessors' points of view, especially in Asia, where the nature of the student-tutor relationship is relatively hierarchical. This study seeks to compare the strengths, limitations, and feedback of the mini-CEX between assessors and students. MATERIALS AND METHODS: A cross-sectional study was conducted among 275 senior medical undergraduates at the National University of Singapore and 121 clinical tutors from seven restructured hospitals in Singapore. Data was collected via a self-administered questionnaire. Univariate analysis was used to determine the prevalence of responses, as well as differences between tutors and students. RESULTS: The mini-CEX provided immediate feedback and timely correction of mistakes. However, effective administration was limited by inter-tutor variability and lack of time. Students reported being receptive to feedback, but tutors disagreed and felt that students were resistant to negative feedback. Additionally, students felt that their performance was compared unfairly against more senior students, although the tutors felt otherwise. CONCLUSION: The mini-CEX is an effective assessment tool, but is limited by barriers to administration and evaluation. Differing opinions and expectations between tutors and students could provide an interesting focal point for future studies.