The Importance of Learning with Patients: Post-Pandemic Takeaways on Learning Professionalism in Clinical Settings.

Background: Public demands for high-quality healthcare require medical schools to ensure that physicians attain various competencies, including professionalism and humanism. This can be accomplished through various interactions and socialisations within the healthcare community. These meaningful learning experiences become more critical as students face unpredictable learning opportunities in clinical settings. However, professional development focuses on lapses, remediation and knowledge retention rather than its practice. To nurture professional and humanistic physicians, this study explores how medical students perceive learning professionalism in clinical settings. Methods: This is a qualitative phenomenology study involving medical students in clinical rotations at the Faculty of Medicine Universitas Indonesia. Respondents were chosen through a purposive sampling method that considered their gender and clinical years. Data were collected through focus group discussions (FGDs) and thematic analysis was used. Results: Three FGDs were conducted with 31 clinical students. Learning professionalism in clinical settings presents challenges, including the hidden curriculum (HC), limited exposure to patients and the clinical learning environment because of the social restrictions caused by the COVID-19 pandemic. The tailored strategy to learn professionalism in the clinical learning environment was more teacher-driven, including role modelling, debriefing, providing feedback and teaching context-specific knowledge on professionalism, followed by patient interactions. Conclusion: The significance of students' interactions with the clinical learning environment, especially with patients and clinical teachers as role models, is the key to learning professionalism in clinical settings. This finding is an important takeaway in curriculum design for professionalism.

Deconstructing the professional identity formation of basic science teachers in medical education.

PURPOSE: The role of basic science teachers (BSTs) in medical education has been changing dynamically. Less is known, however, about how BSTs perceive their professional identity and what factors influence its formation. This study aims to explore how the professional identity of BSTs is formed and what factors influence this professional identity formation (PIF) using the 4S ("Situation, Self, Support, Strategies") Schlossberg framework. METHOD: A qualitative descriptive study using focus groups (FGs) was conducted. Maximum variation sampling was used to purposively select BSTs. A rigorous thematic analysis was completed, including independent thematic analysis, intermittent checking and iterative discussions among researchers, and member checking. RESULTS: Nine FGs, involving 60 teachers, were conducted. The findings highlighted four major themes reflecting the 4S framework: the self as internal driver, early-career events and opportunities, individual and institutional support, and active participation in continuing professional development. Both the "Self" and the "Situation" components prompted the BSTs to utilize supports and enact strategies to become professional teachers. Although the BSTs in this study were primarily internally driven, they relied more on existing support systems rather than engaging in various strategies to support their growth. CONCLUSION: It is important to address the PIF of BSTs given their dynamic roles. Looking through the lens of the 4S framework, PIF is indeed a transition process. A structured, stepwise faculty development program, including mentorship, reflective practice, and a community of practice designed to foster BSTs' identities, should be created, taking into consideration the diverse factors influencing the PIF of BSTs.

Exploring College Adjustment in First-Year Gen Z Medical Students and Its Contributing Factors.

Background: First-year medical students need to adjust to university life to achieve optimal education. Notably, generation Z (Gen Z) students recently admitted to medical school possess unique characteristics that may affect their adjustment. However, limited studies have evaluated the adjustment of Gen Z medical students. In line with this, the present study explores the adjustment process of Gen Z medical students in their first year of study. Methods: A qualitative phenomenological study was held from January 2020 to October 2020. The respondents comprised first-year students from two medical institutions. Maximum variation sampling was applied to select the respondents. Moreover, 11 focus group discussions (FGDs) with students and 10 in-depth interviews with lecturers were conducted. Curriculum documents were examined, and then the data were analysed thematically. Results: Three themes were identified: i) domain; ii) process and iii) contributing factors to college adjustment. Academic, social and personal-emotional components of adjustment were included in the domain theme. The process theme consisted of transition, transition-transformation and transformation phases. Meanwhile, the contributing factors consisted of existing and supportive factors. Student characteristics, including demographics, mentality, prior educational experiences and social support, were considered the existing factors, while technology, learning system and well-being constituted the supporting factors. Conclusion: College adjustment involves various domains, processes and contributing factors that are unique to Gen Z characteristics, technology dependence and culture. Therefore, well-prepared faculties are needed to support the adjustment of Gen Z students.

Professional identity formation of medical teachers in a non-Western setting.

INTRODUCTION: Understanding and supporting professional identity formation (PIF) among medical teachers has become increasingly important in faculty development programs. In this study, we explored medical teachers' PIF in Indonesia. METHODS: We conducted a qualitative descriptive study using focus group discussions (FGDs) at four medical schools in Indonesia. Basic science and clinical teachers from four different schools were selected to participate. Data were transcribed, coded, and analysed to develop themes and subthemes. RESULTS: Seventeen FGDs were completed, involving 60 basic science and 59 clinical teachers. Four major themes regarding the formation of medical teachers' professional identity emerged: an internal dialogue between intrinsic values and external influences, empowerment through early socialization, experiential workplace learning, and envisioning the future. The PIF process was similar for basic science and clinical teachers. CONCLUSION: Our findings suggested that PIF among medical teachers in a non-Western setting is a continuous and dynamic process that is shaped by key socialization factors (e.g. role models, workplace learning, peer support), with significant influences from religious beliefs, family values, and societal recognition. Faculty development programs should consider the dynamic and continuous nature of PIF among medical teachers and encourage clinicians and basic scientists to explore their values and beliefs, realize their goals, and envision their future.

Evaluating the Relationship Between Online Learning Environment and Medical Students' Wellbeing During COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has been found to negatively affect medical students' wellbeing. This finding may be related to how medical education is being conducted at present, with online learning replacing face-to-face teaching in many countries. This cross-sectional study aims to assess how the online learning environment is connected to medical students' wellbeing. METHODS: A self-administered online questionnaire was distributed to undergraduate medical students at Universitas Indonesia. The study was conducted from September 2020 to February 2021. The questionnaire included a modified version of the Online Learning Environment Scale (OLES) and the Positive Emotion, Engagement, Relationships, Meaning and Accomplishment (PERMA) profiler. The OLES was used to evaluate students' perceptions of the online learning environment, whereas the PERMA Profiler was used to evaluate students' wellbeing. We validated the questionnaire before distribution. The content validity index was 1.0, with internal consistency coefficients of 0.87 and 0.89, respectively. Regression analyses were performed to evaluate the relationship between OLES and PERMA scores. RESULTS: The questionnaire was completed by 274 undergraduate medical students. Students reported moderate to high degrees of positive perception towards online learning, high levels of positive emotions and moderate levels of negative emotions. Statistically significant differences were found across groups based on students' gender, year of study and academic programme. Almost all aspects of the online learning environment were significantly predictive of students' wellbeing, with personal relevance and evaluation and assessment being the two most important predictors (R 2 = 0.201; P < 0.001). CONCLUSION: Medical students generally enjoyed online learning, although some challenges were presented. The online learning environment was positively associated with students' wellbeing; however, some students expressed negative emotions including loneliness, anxiety, anger and sadness.

Development of e-portfolio in undergraduate clinical dentistry: How trainees select and reflect on evidence.

INTRODUCTION: Self-reflection is a fundamental part of health professional development, especially in the unstructured clinical stage of dentistry, medical and health profession education, since it plays important role in experiential learning. A portfolio-both conventional and digital-records various aspects of knowledge, skills and attitudes over a long period of time to help students develop their professionalism by conducting self-reflection. This study aims to explore the process of selecting and reflecting on professionalism evidence recorded in e-portfolios during undergraduate clinical dentistry training. METHOD: This pilot study is a qualitative study with a phenomenological design. The selection of respondents was conducted using a maximum variety sampling method. Following a 6-week pilot programme, a total of six in-depth interviews and five focus group discussions were conducted with undergraduate students representing different clinical rotations to explore the process conducted by undergraduate clinical dentistry students in e-portfolio development. The study of documents was also conducted on the respondents' reflective writing from the e-portfolio back-end data to explore their self-reflection skills. RESULT: The results of the present study highlighted two different approaches used amongst trainees in developing a reflective e-portfolio: selective and non-selective. The observed reflective e-portfolio utilisation frequency and trainees' self-reflection skills were low, with several affecting factors identified. These identified factors consisted of external factors, such as the undergraduate clinical dentistry programme curriculum, the hidden curriculum, the availability of feedback, the availability of role models, and features of the e-portfolio and internal factors, such as understanding the self-reflection concept, the availability of time and mood, cultural factors, and understanding the content reflected. CONCLUSION: Through the process of independently selecting and recording learning activities in e-portfolios as well as repeatedly conducting self-reflection, trainees can improve their overall reflective abilities. However, producing a systematic approach to forming a reflective learning environment is necessary to aid the implementation of reflective e-portfolios, especially at the early stage of e-portfolio implementation.

Dealing with negative role modelling in shaping professional physician: an exploratory study.

OBJECTIVE: To explore negative role modelling by medical teachers in developing professionalism. METHODS: The qualitative study using a transcendental phenomenology design was conducted at at Tanjungpura University, Indonesia, from December 2017 to February 2018, and comprised of 6 medical students from academic phase, 6 medical students from clinical phase, 8 medical teachers, 4 clinical teachers, 6 alumni and 5 programme managers. Data was collected through 5 focus group discussions and 5 in-depth interviews. Thematic analysis was applied to explore negative role modelling in the pre-clinical and clinical phase of the learning process. Data was analysed using the steps for coding and theorisation method. RESULTS: There were 30 respondents in five focus group discussions and 5 interviews were held with programme managers. There were three themes identified: medical teacher as a role model, process of role modelling, and nurturing medical professionalism. The presence of negative role modelling was evident in the discussions. Both positive and negative role modelling could influence the medical professionalism. Negative role modelling of medical teachers is a phenomenon often found in medical professionalism development. CONCLUSIONS: Negative role modelling requires a more active process to develop professionalism.

Unveiling the Hurdles in Cultivating Humanistic Physicians in the Clinical Setting: An Exploratory Study.

BACKGROUND: The importance of cultivating a humanistic physician has gained attention in medical education. Humanistic values are established in early education and medical schools should provide a suitable environment to nurture and grow these values into professional identity. The clinical setting has a significant impact due to its direct involvement of students in real-life situations. OBJECTIVES: The present study aims to explore the hurdles in cultivating humanistic physicians in the clinical setting. METHODS: We conducted a qualitative study involving medical students in the clinical phase, as well as residents, clinical teachers, and module administrators in the clinical setting under study. RESULTS: Respondents from different groups of stakeholders shared the same definition for 'humanistic physician': a physician who provides patient-centred care while demonstrating empathy, respect, compassion, integrity, knowledge, competence and a collaborative spirit. Despite changes in the healthcare system and technological advancements, humanistic physicians are still needed. CONCLUSION: Cultivating humanistic physicians is a complex process, requiring various methods and assessments. Role models play a significant role in this process, which included not only clinical teachers but also peers. Feedback from peers was perceived as an important factor. The key hurdles identified were negative role models, and a less humanistic learning environment and the students' personal backgrounds.

Formulating a Need-Based Faculty Development Model for Medical Schools in Indonesia.

BACKGROUND: The focus of medical schools in developing countries is on fulfilling a quantity of faculty members. A faculty development model will help formulate programmes that accommodate faculty members' needs as well as institutional demands. This study aims to formulate a faculty development model relevant for medical schools in developing countries, specifically Indonesia. METHODS: This is a qualitative study with a phenomenological approach. It starts with a literature review using large databases, followed by interviews with 10 representative experts from medical schools in Indonesia. RESULTS: Based on the 10 studies retrieved, several components of faculty development were identified as the basis for the model. Ten experts gave input for the model. Components of the model can be grouped into: (i) content, which is materials that need to be delivered; (ii) process components, which depict aspects related to the preparation, execution and evaluation of sustainable faculty development; and (iii) components in the educational system that affect faculty development implementation. CONCLUSION: A comprehensive review and development process has likely made this faculty development model suitable for medical schools in Indonesia. Breaking the model into components may help medical schools to prioritise certain aspects related to faculty development programmes.

Redesigning a faculty development program for clinical teachers in Indonesia: a before-and-after study.

PURPOSE: Faculty development (FD) is important to support teaching, including for clinical teachers. Faculty of Medicine Universitas Indonesia (FMUI) has conducted a clinical teacher training program developed by the medical education department since 2008, both for FMUI teachers and for those at other centers in Indonesia. However, participation is often challenging due to clinical, administrative, and research obligations. The COVID-19 pandemic amplified the urge to transform this program. This study aimed to redesign and evaluate an FD program for clinical teachers that focuses on their needs and current situation. METHODS: A five-step design thinking framework (empathizing, defining, ideating, prototyping, and testing) was used with a pre/post-test design. Design thinking made it possible to develop a participant-focused program, while the pre/post-test design enabled an assessment of the program's effectiveness. RESULTS: Seven medical educationalists and four senior and four junior clinical teachers participated in a group discussion in the empathize phase of design thinking. The research team formed a prototype of a 3-day blended learning course, with an asynchronous component using the Moodle learning management system and a synchronous component using the Zoom platform. Pre-post-testing was done in two rounds, with 107 and 330 participants, respectively. Evaluations of the first round provided feedback for improving the prototype for the second round. CONCLUSION: Design thinking enabled an innovative-creative process of redesigning FD that emphasized participants' needs. The pre/post-testing showed that the program was effective. Combining asynchronous and synchronous learning expands access and increases flexibility. This approach could also apply to other FD programs.

Deeper look into feedback practice in an Indonesian context: exploration of factors in undergraduate clinical settings.

PURPOSE: The practice of feedback is influenced by the characteristics of students, teachers, and the clinical environment. Most studies on feedback have been conducted in Western settings with different sociocultural backgrounds to Indonesia. This study explores feedback in Indonesian clinical clerkship using a sociocultural lens and aims to provide an exemplar of adaptive practice relevant to non-Western settings. METHODS: This qualitative study was conducted using an interpretive phenomenology approach. Data were collected through focus groups with students and teachers and interviews with program coordinators. Data were transcribed verbatim and grouped according to data sources, coded, and analyzed thematically. RESULTS: Themes identified from the focus group discussions and interviews were categorized as student, teacher, and environmental factors. Student factors include dependence on feedback, tendencies to use a group approach, difficulties recognizing social rules, a perceived lack of resilience, and tendencies to doubt praise. Factors related to teachers include a high level of expertise, being extremely busy, having a strong commitment, and being unsure of students' acceptance of feedback. Clinical environment factors influence interactions between teachers and learners and include high power distance and collectivistic values. A safe environment is needed to ensure effective feedback interactions. CONCLUSION: High power distance, collectivism, and generational characteristics of students likely impact feedback practice in clinical settings. Designing a safe environment is essential for effective feedback practice.

Looking beyond the COVID-19 pandemic: the recalibration of student-teacher relationships in teaching and learning process.

BACKGROUND: Given the various novel educational approaches and online interactions following the pandemic, it is timely to identify lessons learned for post-pandemic student and teacher relationships within the 'new normal' teaching learning processes. This study aims to explore the dynamics and to what extent the disruption influences student-teacher relationships in teaching and learning process following the COVID-19 pandemic. MATERIALS AND METHODS: A qualitative descriptive approach was employed to explore individual reflections and perspectives from 28 medical teachers and 35 medical students from different institutions who participated in 10 focus groups. Data were analyzed thematically using steps for coding and theorization (SCAT) approach. The emerging themes were then further analyzed and regrouped into the relationship-centered leadership framework based on emotional intelligence. RESULTS: The identified themes described three elements representing student-teacher relationships in the teaching learning processes. The self as the center of the diagram consists of the co-existing role of the self as teachers and as students, which to some extent, is related to their personal and professional development, motivation, and struggles to maintain work-life balance. The middle layer represents the dynamic of student-teacher relationship, which showed that despite the increased number of teaching opportunities, the trust among teachers and students was compromised. These changes in the self and the dynamic relationship occurred in a broader and more complex medical education system, pictured as the outer layer. Thorough curriculum improvements, contents, and new skills were emphasized. CONCLUSIONS: Our findings emphasized the need to recalibrate student-teacher relationships, taking into account the intrapersonal, interpersonal, and the system factors. The pandemic has reemphasized the aim of teachers' roles, not only to nurture students' competencies, but also to nurture meaningful interpersonal reciprocal relationships through responding towards both teachers' and students' needs as well as supporting both personal and professional development.

Impact of Women's Domination in Plastic Surgery Residency Program in Indonesia.

A shift in gender dominance from man to woman in the medical field has occurred from time to time globally, including in Indonesia's plastic surgery community. This shift may alter the education and clinical settings of plastic surgery. This study aimed to explore the effect of the phenomenon of women's dominance in plastic surgery residency programs in Indonesia. METHODS: This qualitative study was conducted using a phenomenological approach on three plastic surgery residency programs in Indonesia. Academic report review, focus group discussions, and in-depth interviews of residents, lecturers, residency program managers, and alumni user groups were selected using the maximum variation sampling method. Data obtained were analyzed and processed thematically. RESULTS: Three themes emerged based on the educational process timeline: pre-education, intra-education, and post-education. Each timeline had several themes that mutually influenced the educational process. In the pre-educational process, residents' personal characters were affected by societies' positive and negative perceptions. The working environment, impact of women's dominance, and cultural dimension affected the intra-educational process. When entering the career life, residents expected an ideal working environment and had particular workplace preferences to achieve their well-being. CONCLUSIONS: The impact of women's dominance during the educational program affected residents' daily dynamics. However, this dominance did not affect the quality of education and workloads.

"To obey or not to obey" - Medical students' response towards professional dilemmas in a hierarchical and collectivist culture.

BACKGROUND: Clinical clerkship programme in medical schools were developed to provide students with direct interactions with patients and observe clinical teachers in practice. However, professional dilemmas are prone to occur due to the nature of experiential learning. Several studies across different cultures showed that medical students responded differently towards professional dilemma. AIMS: This study aims to explore how medical students respond to professional dilemmas occurred during their clinical clerkships and to what extent culture influences the responses. METHOD: A qualitative descriptive approach was used in this study. We conducted four focus group discussions with final year medical students who were selected using maximum variety sampling method. Thematic analysis was conducted following the transcription of the focus groups. RESULTS: We identified the impact of dilemmas on students' emotions and concerns, students' responses towards professional dilemmas, and factors affecting responses to dilemmas in clinical clerkship, which confirmed that cultures played roles in how students responded towards professional dilemmas. CONCLUSION: This study has identified that culture, to some extent, influenced the way students responded to professional dilemmas. Therefore, it is paramount to develop a conducive and culturally sensitive educational environment and students' ability to learn from professional dilemma experienced in the workplace for developing their professional identity.

Trainees' perceptions and expectations of formal academic mentoring during the COVID-19 pandemic in Indonesian cardiology residency programs.

PURPOSE: During medical residency programs, physicians develop their professional identities as specialists and encounter high expectations in terms of achieving competencies. The responsibilities of medical trainees include caring for patients, balancing work with personal life, and weathering stress, depression, and burnout. Formal academic mentoring programs strive to ease these burdens. The coronavirus disease 2019 (COVID-19) pandemic has altered the trainee­academic mentor relationship, and solutions are needed to address these challenges. The present study aimed to evaluate the formal academic mentoring process through trainees' perceptions and expectations of formal mentoring programs during COVID-19 in Indonesian cardiology residency programs. METHODS: This cross-sectional study used a self-administered online questionnaire to capture trainees' perceptions and expectations regarding academic mentoring programs in 3 cardiology residency programs in Indonesia from October to November 2020. The questionnaire was developed before data collection. Perceptions of the existing mentoring programs were compared with expectations. RESULTS: Responses were gathered from 169 out of 174 residents (response rate, 97.3%). Most trainees reported having direct contact with COVID-19 patients (88.82%). They stated that changes had taken place in the mode and frequency of communication with their academic advisors during the pandemic. Significant differences were found between trainees' perceptions of the existing mentoring programs and their expectations for academic mentoring programs (P<0.001). CONCLUSION: Despite the challenges of interacting with their academic mentors, trainees still perceived academic mentors as a vital resource. Study programs need to consider trainees' expectations when designing academic mentoring programs.

Relationship between empathy and motivation in undergraduate medical students.

Background: Undergraduate medical education is important for encouraging empathy which is a critical component of patient-physician communication. Studies show a decline in empathy once medical students enter their clinical years. Since empathy is also a "motivated phenomenon", the current study aims to explore the relationship between empathy and students' motivation types. Methods: This cross-sectional study used a total sampling approach to recruit medical students in years 1-5. The Jefferson Scale of Physician Empathy (JSPE) was used to measure empathy in medical students and the Academic Motivation Scale (AMS) was utilised to assess student motivation. Following descriptive analyses, the differences in empathy scores based on motivation type was assessed using Kruskal-Wallis test and post-hoc Mann-Whitney test. Furthermore, the Spearman's rank correlation analysis was completed to assess the relationship between students' empathy and motivation type. The analyses were completed for each of year 1-5. Results: A total of 827 completed questionnaires (71.3% response rate) were analysed, showing strong internal consistency. Most students displayed high intrinsic and high controlled motivation. Motivation type was found to be consistently associated with empathy. Conclusions: The present study highlights the association of motivation with empathy in undergraduate medical students with an increasingly low empathy score the more the motivation profile is towards being Low Intrinsic and Low Controlled.

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.

Decreased expression of Apaf-1 with progression of melanoma.

Defects in apoptotic system may contribute in the pathogenesis and resistance of malignant melanoma cells to chemotherapy. Apoptotic protease-activating factor-1 (Apaf-1) is a cell death effector that acts with cytochrome c and caspase-9 to mediate apoptosis. Recently it was shown that metastatic melanomas often lose Apaf-1 and are concomitantly resistant to apoptosis. It is not known, however, whether Apaf-1 protein is lost during melanoma progression from localized to metastatic tumor. To this end, we evaluated Apaf-1 protein expression by immunohistochemistry in 10 cases of human nevi, 11 melanomas in situ, 26 primary melanomas and 15 metastases. Significant decreases in Apaf-1 expression was observed when comparing nevi and melanomas (chi-square = 33.719; P < 0.0001). Moreover, primary melanomas with greater tumor thickness showed lesser expression of Apaf-1 (chi-square = 16.182; P < 0.003). Intriguingly, we were unable to detect Apaf-1 expression in lesions of metastatic melanomas. These data demonstrated that there is an inverse correlation between Apaf-1 expression and pathologic stage of melanoma. This suggests that the decreased expression of Apaf-1 seen in correlation with melanoma progression renders melanoma more resistant to chemotherapy.