To be or not to be: a critical realist exploration of factors motivating doctors in their commitment to improve their teaching practice in a clinical setting in Oman

Abstract

Adopting a critical realist framework, this study explored how medical doctors come to understand and espouse, or resist, their roles as teachers in clinical settings and how they seek to become more proficient in that role. This work builds on earlier research on doctors’ professional development as teachers and extends it into the particular cultural context of medical practice and education in the Sultanate of Oman. A qualitative approach was adopted. Data were collected in 2016 through semi-structured in-depth interviews with 27 senior clinicians and by the examination of relevant institutional policy documents. Interviews were conducted in two hospital settings: the Sultan Qaboos University Hospital (SQUH) and the Royal Hospital (RH), which is a Ministry of Health Hospital (MoHH). The findings suggest that Omani medical doctors’ orientation to their roles as teachers and their understanding of their responsibility to prepare the next generation of medical professionals have been transformed by three main events over the last 3 decades. First was the establishment of Sultan Qaboos University College of Medicine and Health Sciences (CoMHS) in 1986. Next came the governmental authorities’ decision to train medical doctors in the overseas hospitals that have structured postgraduate clinical training since the 1990s. Thus, while the senior doctors contributing to this study had received some or all of their medical training outside of Oman, they were helping to build a medical education system which sought to raise the next generations of doctors at home. Finally came the establishment of the Oman Medical Speciality Board (OMSB) in 2006 as the official body responsible for the graduate medical education in Oman. However, due to a lack of clear policy regarding their teaching roles, the Ministry of Health (MoH) doctors felt that they, as compared to their colleagues in the university teaching hospital (SQUH), were being expected to make an extra effort to teach in their clinical setting. All respondents, whether recruited from RH or SQUH, recognised the influence their own experience of being taught had on their personal development as clinical teachers on their return to Oman. Respondents’ exposures to different teaching and learning cultures and styles contributed to their motivation to teach and learn about teaching. In particular, many respondents believed that the religious culture of the country contributed to a pervasive attitude of altruism in the orientation of doctors to both their patients and their students. However, demotivators such as the health system’s hierarchical structure, unclear educational roles, lack of resources—time, human and suitable facilities—for teaching in their hospitals are significant challenges in accomplishing their multiple roles and developing themselves for their educational roles. What emerged as a fundamental challenge for the RH respondents was the lack of any clear policy regarding the doctor’s role as a teacher. The respondents believed that having a clear policy would empower the doctors and give them the support they need for their multiple roles in the clinical setting. Such policy would also guide the administrators and decision-makers in the support and resourcing that they provide to doctors, which they believed were so essential to ensure the next generation of doctors developed according to Oman’s mission and vision. This study’s findings show clearly the need to establish and standardise national medical education policy and procedures for the MoH doctors, thus giving them a clarity of roles and responsibilities they believe to exist for their SQUH colleagues. Having such national standards and policy is an essential part of a health organisation, and hence its implication for the doctors will be to provide them with the road map for the day-to-day management of their multiple complex roles. It is also clear that the Ministry of Health and the educational institutions (governmental and private at both the undergraduate and the postgraduate levels) need to collaborate and cooperate to establish an integrated medical education system for clinical settings, not just for the learners but also for the doctors who teach them, and thus to establish a stable teaching and learning environment. The presence of such a national policy for medical education will have a positive impact upon the quality of medical education, patient care, and upon junior doctors’ willingness to pursue careers as medical educators in clinical settings