Feedback during clerkships: the role of culture

Achtergrond: De invloed van feedback op het leerproces en functioneren van de student is genoegzaam bekend en ook is duidelijk dat deze door culturele factoren worden beïnvloed. Er zijn echter niet veel studies die deze invloed met ervaring en onderzoek onderbouwen. Doel: In dit proefschrift wordt de rol die cultuur speelt bij feedbackprocessen in de medische opleiding onderzocht. Indonesië wordt hierbij beschouwd als een land met een laag individualisme en hoge “power distance”, termen zoals die door Hofstede gedefinieerd zijn. Methoden: Aan de Universitas Gadjah Mada, Indonesië werden vijf onderzoeken verricht. Allereerst werd er een Nederlandse studie overgedaan waarbij verschillen in feedback processen en hun invloed op het leereffect, als door studenten waargenomen, werden onderzocht. In de tweede plaats werd dit zelfde leereffect bekeken waar het ging om individuele feedback en feedback in groepsverband. Ten derde worden de uitdagingen bij het invoeren van de mini-CEX als instrument om feedback tijdens co-schappen te verbeteren beschreven. In een vierde studie onderzochten we in hoeverre de mini-CEX door studenten en docenten werd gewaardeerd. Tenslotte gingen we in een vijfde studie de invloed van feedback elementen, die via de mini-CEX werden gefaciliteerd, op het leerproces, weer zoals dat door studenten werd ervaren, na. Resultaten: Er zijn tussen beide landen significante verschillen wat betreft feedback processen en ook wat betreft de factoren (en het gebruik hiervan) die het effect van feedback, zoals waargenomen door de student, beïnvloeden. In Indonesië was feedback in een groep van wezenlijk belang voor het leerproces tijdens de co-schappen. Het was daar goed mogelijk om de mini-CEX in te voeren, docenten en studenten waardeerden de mini-CEX positief. Van sommige feedback elementen kon het nut aangetoond worden, van andere niet. Conclusie: Wanneer het gaat om het invoeren van internationale methoden voor feedback, ten einde het leerproces te verbeteren, moet men culturele invloeden die in de leeromgeving gelden onderkennen en in het proces betrekken

Tingkat Stres Pada Mahasiswa Tingkat Profesi Fakultas Kedokteran Universitas Gadjah Mada

ABSTRACT Background: Professional education program is a very important component of general medical education. The success rate in this stage of clinical really determines the quality of health service in our community at present and in the future. The transition process from academic program into clinical program and other problems that come up as the result of an individual student\u27s interaction with the clinical education environment may cause stress to the student. This kind of stress will influence both the students\u27 learning achievement and the quality of medical graduates. This research reveals the stress level of the students of clinical stage and the role of clinical system in causing the stress. Objectives: 1.To recognize the stress level of Gadjah Mada medical students of the clinical stage in every department and whether there were any significant stress level among them. 2. To know whether any significant stress level difference exists between the Major Group Department and the Minor Group Department. 3. To know whether any significant stress level difference exists amongst the students based on sex and other demographic data. Methods: A non-experimental research was conducted with a cross sectional study design. The research utilized closed questionnaires, each contained 4 liken scales. The questionnaires were given to all clinical stage Gadjah Mada medical students in year 2001, and then they were analyzed to find the means. These were used to know the academic, social, and personal stress levels. To be able to know whether any significant differences exist amongst the subjects\u27 characteristic groups, we used ANOVA One Way with Tukey HSD analysis and T-test Samples Independent statistic method. Results: 1. From 2004 Gadjah Mada medical students of the clinical stage, it is found that there were not any significant differences academic stress levels among Department but there were very significant differences on social and personal stress levels. 2. There were not any significant differences between the academic, social, and personal stress levels of male and female Gadjah Mada medical students of the clinical stage. 3. There were not any significant differences between the academic stress level of the second year clinical stage students and the first year clinical stage studentshowever there were significant differences between the social and the personal stress levels of the second and first year clinical stage students. 4. There were not any significant differences between academic, social, and personal stress levels between the Major Group Department and the Minor Group Department. 5. There were not any significant differences between academic, social, and personal stress levels among students residence. Conclusion: The social and personal stress level of the medical student is affected by how long one has been through the clinical rotation and at what department one is in, whilst the academic stressors are quite the same for every group and situation. Key words: Clinical education-stress level-clinical stage student-academic stress-social stres-personal stress

How students and specialists appreciate the mini-clinical evaluation exercise (mini-CEX) in Indonesian clerkships

Background Cultural differences might challenge the acceptance of the implementation of assessment formats that are developed in other countries. Acceptance of assessment formats is essential for its effectiveness; therefore, we explored the views of students and specialists on the practicality and impact on learning of these formats. This study was conducted to explore Indonesian students' and specialists' appreciation of the implementation of the Mini-Clinical Evaluation Exercise (Mini-CEX) in Indonesian clerkships. Methods This study was conducted at the Universitas Gadjah Mada, Indonesia. Participants were 52 students and 21 specialists in neurology and 78 students and 50 specialists in internal medicine. They were asked to complete a 19-item questionnaire that covered the characteristics of the mini-CEX such as its practicality, and the impact on learning and professional development. We used a Mann-Whitney U test to analyse the data. Results In total, 124 students (46 from neurology and 78 from internal medicine) and 38 specialists (13 from neurology and 25 from internal medicine) participated in this study. Students and specialists were positive about the practicality of the mini-CEX and the impact of this assessment format on learning and on professional development. The Mann-Whitney U test showed that there were no significant differences between students' and specialists' opinions on the mini-CEX, except for 2 items: specialists' appreciation of direct observation (mean rank = 93.16) was statistically significantly higher than students' appreciation of it (mean rank = 77.93; z = 2.065; p <0.05), but students' appreciation of the item that students' past mini-CEX results affected their recent mini-CEX outcomes (mean rank = 85.29) was significantly higher than specialists' appreciation of it (mean rank = 69.12; z = 2140; p <0.05). Conclusion Students and specialists were positive about the mini-CEX in Indonesian clerkships, although it was developed and validated in another culture. We found only small differences between their appreciations, which could be explained by the patterns of specialist-student interaction in Indonesian culture as large power distance and low individualism country

Influence of feedback characteristics on perceived learning value of feedback in clerkships: does culture matter?

Background: Various feedback characteristics have been suggested to positively influence student learning. It is not clear how these feedback characteristics contribute to students' perceived learning value of feedback in cultures classified low on the cultural dimension of individualism and high on power distance. This study was conducted to validate the influence of five feedback characteristics on students' perceived learning value of feedback in an Indonesian clerkship context. Methods: We asked clerks in Neurology (n = 169) and Internal Medicine (n = 132) to assess on a 5-point Likert scale the learning value of the feedback they received. We asked them to record whether the feedback provider (1) informed the student what went well, (2) mentioned which aspects of performance needed improvement, (3) compared the student's performance to a standard, (4) further explained or demonstrated the correct performance, and (5) prepared an action plan with the student to improve performance. Data were analyzed using multilevel regression. Results: A total of 250 students participated in this study, 131 from Internal Medicine (response rate 99%) and 119 from Neurology (response rate 70%). Of these participants, 225 respondents (44% males, 56% females) completed the form and reported 889 feedback moments. Students perceived feedback as more valuable when the feedback provider mentioned their weaknesses (beta = 0.153, p <0.01), compared their performance to a standard (beta = 0.159, p <0.01), explained or demonstrated the correct performance (beta = 0.324, p <0.001) and prepared an action plan with the student (beta = 0.496, p <0.001). Appraisal of good performance did not influence the perceived learning value of feedback. No gender differences were found for perceived learning value. Conclusions: In Indonesia, we could validate four out of the five characteristics for effective feedback. We argue that our findings relate to culture, in particular to the levels of individualism and power distance. The recognized characteristics of what constitutes effective feedback should be validated across cultures

Clinical workplace learning:perceived learning value of individual and group feedback in a collectivistic culture

Abstract Background Feedback is essential for workplace learning. Most papers in this field concern individual feedback. In collectivistic cultures, however, group feedback is common educational practice. This study was conducted to investigate the perceived learning value and characteristics of individual and group feedback in a collectivistic culture. Methods During two weeks, on a daily basis, clerkship students (n = 215) from 12 clinical departments at Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia, recorded individual and group feedback moments by using a structured form: the providers, focus and perceived learning value of feedback. Data were analysed with logistic regression and multilevel techniques. Results Students reported 2687 group and 1535 individual feedback moments. Group feedback more often focused on history taking, clinical judgment, patient management, patient counselling, and professional behaviour (OR ranging from 1.232, p < .01, to 2.152, p < .001), but less often on physical examination (OR = .836, p < .01). Group feedback less often aimed at correcting performance deficiencies (OR = .523, p < .001) and more often at comparing performance to the standard (OR = 2.447, p < .001) and planning action to improve performance (OR = 1.759, p < .001). Group feedback was perceived as more valuable than individual feedback (M = 4.08 and 3.96, respectively, β group  = .065, SE = .026, p < .01). Conclusion In collectivistic cultures, group feedback may add to the array of educational measures that optimize student learning. Congruence between culture and type of feedback may be important for the effectiveness of feedback

The Encounters of Clinical Teaching in Hierarchical and Collectivistic Contexts

The socio-hierarchical context brings many consequences to student-centered learning, not only in the classrooms but also in clinical settings. The ideal observation-based learning may not work as expected during workplace-based clinical education and patient-care services. The ultimate summative assessment, which will be discussed in another chapter, will drive students' motivation to pass the final clinical examination as if it is the only way to succeed in their clinical education. Therefore, clinical learning likely lacks dialogue, supervision, observation, and feedback. Constructive comments are rare, as well as self-reflection, participatory learning, and initiatives. Using an experience-based learning model as the concept for clinical teaching in the 21st century, we discuss the difficulties and challenges of the country with collectivist and large power distance cultures. To implement the concept of clinical teaching in this cultural context medical teachers should be aware of tension between precondition for implementing the concept and cultural countries characteristics. In a collectivistic culture, serial discussions should be taken to reduce this tension while keeping the underlying ideal clinical teaching. We shared our experience in implementing innovation to improve clinical teaching in a hierarchical and collectivistic cultural context. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022, corrected publication 2022

The Encounters of Clinical Teaching in Hierarchical and Collectivistic Contexts

The socio-hierarchical context brings many consequences to student-centered learning, not only in the classrooms but also in clinical settings. The ideal observation-based learning may not work as expected during workplace-based clinical education and patient-care services. The ultimate summative assessment, which will be discussed in another chapter, will drive students' motivation to pass the final clinical examination as if it is the only way to succeed in their clinical education. Therefore, clinical learning likely lacks dialogue, supervision, observation, and feedback. Constructive comments are rare, as well as self-reflection, participatory learning, and initiatives. Using an experience-based learning model as the concept for clinical teaching in the 21st century, we discuss the difficulties and challenges of the country with collectivist and large power distance cultures. To implement the concept of clinical teaching in this cultural context medical teachers should be aware of tension between precondition for implementing the concept and cultural countries characteristics. In a collectivistic culture, serial discussions should be taken to reduce this tension while keeping the underlying ideal clinical teaching. We shared our experience in implementing innovation to improve clinical teaching in a hierarchical and collectivistic cultural context

The determinant factors of medical students' learning behavior in the national medical competency examination in Indonesia: A qualitative study

Indonesia has applied for a national competency exit examination for medical graduates since 2014. This examination has an impact on students. There is limited literature that describes the impact mechanism of the national examination. This study aimed to identify the determinant factors of the learning behavior of medical students in the national medical competency examination during the COVID-19 pandemic in Indonesia. This qualitative study was conducted using semi-structured in-depth face-to-face interviews with 13 medical students from the Faculty of Medicine Universitas Islam Malang and online interviews with 13 medical students from the Faculty of Medicine Universitas Gadjah Mada, Indonesia. Theoretical sampling was carried out by including three medical students from a faculty of medicine in east Indonesia. Semi-structured in-depth interviews with respondents from FK Unisma were conducted offline with strict health protocols. Meanwhile, communications with respondents from FK-KMK UGM and the eastern Indonesia medical faculty were conducted online by telephone or through Zoom meetings. Transcribed interviews were coded openly. Themes were finalized through discussion to reach a consensus. The extracted concepts from our study were classified into 10 categories that describe the determinant factors of learning behavior and two categories of learning behavior. These categories include task value, goal orientation, weakness, impact failure, benefits of passing the examination, self-efficacy, beliefs, barriers to learning, environment factors, and test anxiety. The learning behavior itself consists of two categories: quality of learning and regulation of learning. The conclusion is determinant factors consisting of internal and external factors. Internal factors include task value, goal orientation, weakness, benefits of passing the examination, self-efficacy, belief, and test anxiety. The external factor includes the environmental factor. These factors determine the medical student learning behavior in the national medical competency examination during the COVID-19 pandemic in Indonesia, both in quality and regulation of learning. The impact of failure only determines the regulation of learning, while the barrier to learn only determines the quality of learning. Copyright © 2022 Firmansyah, Suhoyo and Rahayu