Perceptions of the first graduates of the reformed medical curriculum of the College of Medicine at Imam Abdulrahman Bin Faisal University

Abstract

BACKGROUND:

The College of Medicine at Imam Abdulrahman Bin Faisal University reformed its undergraduate program into an integrated, outcomes-based, theme-based, and student-centered program. The present study aimed to determine the perceptions of first graduates on the efficacy of the reformed program and examine the levels of their satisfaction and self-efficacy of the knowledge and skills acquired.

MATERIALS AND METHODS:

The first batch of graduates was invited to participate in this cross-sectional study. An online self-administered questionnaire using a five-point Likert-style scale was used to evaluate the curriculum content, teaching and learning methods, communication with teachers, and assessment methods. It also evaluated graduates’ satisfaction and self-efficacy levels of their acquired knowledge and skills, as well as their level of competence and professional ability. Analysis of variance was applied to differentiate graduates’ perceptions regarding the quality and impact of academic years.

RESULTS:

The strongest subject in the curriculum according to the participants was the subject of ethics, professional and behavioral sciences, with a mean of 4.11 (±1.03). The 5thyear curriculum was rated the highest as regards the quality and impact of individual academic years with a mean of 4.49 (±0.70). Team and multidisciplinary work were rated the highest, with a mean of 4.60 (±0.62) when it came to graduates’ satisfaction and self-efficacy levels on the acquired knowledge and skills. Medical ethics stood out for its content and graduates’ self-efficacy. Most of the graduates revealed that they were ready for work as interns and residents (76%) and were proud to be doctors (81.4%).

CONCLUSION:

The graduating students’ opinions offer valuable information for potential curriculum revisions. Their perceptions of the curriculum design should be explored in greater detail in future qualitative studies. Further internal studies are recommended to enhance the integration of the basic science content and improve assessment and evaluation methods.

Introduction

The College of Medicine at Imam Abdulrahman Bin Faisal University (IAU) reformed the MBBS program in 2014. The updated curriculum was adapted from a highly ranked international medical school to enhance the educational experience. Many medical colleges have reformed their curricula to meet societal needs and address the lack of specialists or the desire to produce more competent physicians.[1] Most reforms involve the introduction of integrated, outcome-based education, a broader definition of competence, and requirements for teaching and assessment.[2] Globally, different models of curricula and frameworks have been introduced under the influence of national bodies and accreditations.[3,4,5] In response, medical colleges have reformed their curricula to meet both international standards and national accreditation requirements.[6,7]

The MBBS program in the College of Medicine at IAU now comprises one preparatory year followed by 5 academic years and another year of an internship training program. The old curriculum consisted of two stages – basic sciences and clinical skills training. The new reformed curriculum was designed to be integrated, outcome-based, theme-based, and student-centered. Different approaches are used to deliver the curriculum; these, include problem-based learning (PBL), case-based learning (CBL), and early clinical and community exposure. It employs a variety of assessment methods: formative, summative, and vertically integrated assessments.

The first batch of students in the reformed program enrolled in 2014 graduated in 2019. The students in this batch represent the first graduates. Their perceptions and feedback are vital for the assessment of the quality and efficacy of the reformed curriculum, the success of its delivery, and the achievement of learning outcomes as well as the support of the curriculum development.[1] Therefore, this study’s aim was to assess the graduates’ perceptions of the efficacy of this reformed MBBS program, the students’ levels of self-efficacy, and satisfaction with the knowledge and skills acquired during the program.

Materials and Methods

This was a cross-sectional study conducted in the College of Medicine at IAU from September 2020 to August 2021 using an online self-administered questionnaire.

The questionnaire included a cover page that described the purpose of the study and assured the participants of the confidentiality of their responses. Ethical approval was obtained from the Institutional Review Board vide Letter No. (IRB-2020-01-207) dated 09/07/2020, and written informed consent was taken from all participants in the study.

A representative sample of the graduates of the reformed curriculum was taken to make up the participants as the first batch of students who had enrolled in the MBBS program in 2014 and graduated in 2019. They were registered as medical interns at the time of the study. There were no inclusion or exclusion criteria.

The questionnaire used in the study, originally developed by Ozan et al.,[5] was modified, developed, and adapted to the purpose and context of the study. The modifications included the incorporation of additional items related to the reformed MBBS program. The questionnaire was translated into Arabic, the native language of the participants targeted in this study. The validity process was assessed by a multi-step approach, including validity evaluation by two experts. A prestudy test for validity was conducted to evaluate the questionnaire’s clarity, reliability, feasibility, and content validity by means of a pilot sample and expert feedback.

The questionnaire was composed of five sections. The first section covered the participants’ basic information. The second evaluated the efficacy of the curriculum contents, teaching and learning methods, communication with teachers and supervisors as well as the assessment and evaluation methods. Evaluation of the curriculum contents included subjects related to basic sciences, clinical sciences, community health sciences besides ethics, professional and behavioral sciences. The third section evaluated the efficacy of each academic year of the reformed program and the overall program, while the fourth evaluated the satisfaction and self-efficacy levels of the graduates on their knowledge and skills acquired in the reformed program. The last section consisted of two single parameters that evaluated the graduates’ level of competence and professional ability relating to their readiness for work as interns and residents besides their sense of pride as doctors.

The questionnaire parameters related to the efficacy, satisfaction, and competency levels were evaluated using a five-point Likert-style scale,[1,2,3,4,5] scale in which “1 was the minimum and 5 was the maximum.” The graduates’ level of pride was evaluated using a scale parameter of (yes, neutral, and no).

Descriptive statistics were used to characterize the sample studied. The quantitative variables were described with means and standard deviations (mean + SD). The qualitative variables were summarized using frequencies and percentages. Student’s paired t-test was used to compare the exact differences in the graduates’ satisfaction scores across the academic years. Analysis of variance was applied to differentiate graduates’ perceptions regarding the quality and impact of academic years. Post hoc test was used to define the exact differences between the academic years. P < 0.05 were considered statistically significant. The data were managed and analyzed using Statistical Package for the Social Sciences software version 21 (SPSS, IBM Corporation, Armonk, NY: USA).

Results

The survey was distributed online to a total of 207 graduates. The overall response rate was 33.8% (a total of 70 respondents). Table 1 presents the evaluation of the strength of the reformed curriculum content. As perceived by the graduates, the highest scores were given to the ethics, professional, and behavioral sciences content, with a mean of 4.11 (±1.03). The lowest scores were pertinent to the assessment and evaluation methods, with a mean of 2.53(±1.11).

Table 1.

Strengths of the contents of newly reformed MBBS curriculum at Imam Abdulrahman Bin Faisal University (n=70)

Item	Minimum	Maximum	Mean±SD
Curriculum content in basic sciences	1.0	5.0	2.71±0.93
Curriculum content in clinical sciences	2.0	5.0	3.86±0.79
Curriculum content in community health sciences	1.0	5.0	3.97±1.05
Curriculum content in ethics, professional, and behavioral sciences	1.0	5.0	4.11±1.03
Use of teaching and learning methods	1.0	5.0	3.47±1.11
Communication with teachers and supervisors	1.0	5.0	2.83±0.93
Assessment and evaluation methods (examinations and assignments)	1.0	5.0	2.53±1.11

SD=Standard deviation

The graduates’ evaluation of the quality and impact of each academic year (2^nd, 3^rd, 4^th, 5^th, and 6^th years) as well as the overall program ranged from 2.71 (±1.15) to 4.49 (±0.70) [Table 2]. The 5^th year had the highest satisfaction score, while the lowest score went to the 2^nd year.

Table 2.

The evaluation of the quality and impact of newly reformed MBBS curriculum at Imam Abdulrahman Bin Faisal University by academic year (n=70)

Item	Minimum	Maximum	Mean±SD	SE
Second year	1.0	5.0	2.71±1.15	0.138
Third year	1.0	5.0	2.99±1.12	0.134
Fourth year	1.0	5.0	2.74±1.22	0.146
Fifth year	3.0	5.0	4.49±0.70	0.083
Sixth year	2.0	5.0	4.07±0.86	0.102
Overall program	2.0	5.0	3.30±0.64	0.077
Total	420 (n=70 for each item)		3.38±0.18	0.058

SD=Standard deviation, SE=Standard error

Table 3 shows graduates’ perceptions about the efficacy of each academic year’s educational program. The results revealed a statistically significant difference in the graduates’ perceptions of the quality and impact of academic years between the 2^nd and 3^rd years at 95% (P < 0.05). Similarly, there was a statistically significant difference in the quality and impact of academic years across academic years (P < 0.01), between the 2^nd and 5^th years, 2^nd and 6^th years, 3^rd and 5^th years, 3^rd and 6^th years, 4^th and 5^th years, 4^th and 6^th years as well as 5^th and 6^th years, respectively. However, no statistically significant difference was observed in the graduates’ perceptions of the quality and impact between the 2^nd and 4^th academic years as well as the 3^rd and 4^th academic years (P > 0.05).

Table 3.

Comparison of the quality and impact newly reformed MBBS curriculum at Imam Abdulrahman Bin Faisal University between academic years (n=70)

Year of study	Mean±SD	Significance difference effect (%)	P-value
Second year	2.714±1.1565	0.27 (5.4)	0.014
Third year	2.986±1.1228
Second year	2.714±1.1565	0.028 (0.56)	0.896
Fourth year	2.743±1.2240
Second year	2.714±1.1565	1.77 (35.4)	0.001
Fifth year	4.486±0.6966
Second year	2.714±1.1565	1.36 (27.2)	0.001
Sixth year	4.071±0.8567
Third year	2.986±1.1228	0.24 (4.8)	0.264
Fourth year	2.743±1.2240
Third year	2.986±1.1228	1.5 (30.0)	0.001
Fifth year	4.486±0.6966
Third year	2.986±1.1228	1.08 (21.6)	0.001
Sixth year	4.071±0.8567
Fourth year	2.743±1.2240	1.74 (34.8)	0.001
Fifth year	4.486±0.6966
Fourth year	2.743±1.2240	1.33 (26.6)	0.001
Sixth year	4.071±0.8567
Fifth year	4.486±0.6966	0.41 (8.2)	0.001
Sixth year	4.071±0.8567

Student paired t-test, significant level at >0.05. SD=Standard deviation

Table 4 shows the graduates’ satisfaction and self-efficacy levels regarding their acquired knowledge and skills from the reformed MBBS program. The evaluation of the graduates’ satisfaction and self-efficacy levels in the studied aspects ranged from 2.67 (±1.05) to 4.60 (±0.62). The highest scores were given to the graduates’ belief in the importance of teamwork and multidisciplinary work, with a mean of 4.60 (±0.62), followed by the acquisition of professional ethics with a mean of 4.53 (±0.65). The lowest scores were given to aspects of the appropriate prescribing of treatments with a mean of 2.67 (±1.05) and knowledge of the administrative duties of a doctor with a mean of 2.83 (±1.09).

Table 4.

The graduates’ satisfaction and self-efficacy levels with newly reformed MBBS curriculum at Imam Abdulrahman Bin Faisal University (n=70)

Item	Minimum	Maximum	Mean±SD
Clinical analysis skills	1.0	5.0	3.71±0.84
Ability to identify own abilities, weaknesses, and educational needs	2.0	5.0	3.97±0.76
Access to scientific references and correct information sources	2.0	5.0	4.20±0.93
Problem-solving skills	2.0	5.0	3.77±0.85
Planning and implementing scientific research	1.0	5.0	3.31±1.29
Medical history taking	3.0	5.0	4.50±0.63
Performing a clinical examination	2.0	5.0	4.23±0.80
Diagnostic analysis and come up with possible differential diagnosis	1.0	5.0	3.96±1.01
Ordering the required tests correctly	2.0	5.0	3.86±0.87
Prescription of the treatment appropriately	1.0	5.0	2.67±1.05
Ability to do some medical interventions safely and with confidence like CPR, IV	1.0	5.0	3.26±1.28
Ability to act in an emergency	1.0	5.0	3.01±1.16
Acquisition of information about the health situation and health priorities in Saudi Arabia	1.0	5.0	3.49±1.16
Acquisition of enough information about preventive medicine	1.0	5.0	3.39±1.22
Acquisition of information about the health system in Saudi Arabia	1.0	5.0	3.21±1.15
Acquisition of information about social and cultural factors and their impact on health	1.0	5.0	3.80±1.07
When dealing with the patient, dealing with him completely, considering the biological, social, and cultural matters	1.0	5.0	4.16±0.99
Awareness of all the legal and regulatory aspects of a doctor’s work	1.0	5.0	3.13±1.10
Knowing the administrative duties of the doctor’s work	1.0	5.0	2.83±1.09
Acquisition of communication skills	1.0	5.0	3.90±0.90
Acquisition of professional ethics	2.0	5.0	4.53±0.65
Believe in the importance of teamwork and multidisciplinary work	3.0	5.0	4.60±0.62
Awareness of teamwork and multidisciplinary work	2.0	5.0	4.29±0.87
Familiarity with health education and the ability to do it	2.0	5.0	4.30±0.84

SD=Standard deviation, CPR=Cardiopulmonary resuscitation, IV=Intravenous

Evaluation of the graduates’ readiness for work as interns and residents in terms of their level of competence and professional ability revealed a mean of 3.79 (±0.8). On the other hand, when asked to rate their level of competence and professional ability to work as interns and residents, 67% of the respondents agreed that they were ready for work as interns and residents, 27% of them were neutral while 6% indicated they were not ready for work.

When asked about whether they were proud of being doctors, most of the graduates (81.4%) revealed that they were proud to be doctors, 14.3% were neutral, while only 4.3% pointed out they had no sense of pride as doctors.

Discussion

This study explored the perceptions of the first graduates of the reformed MBBS program to provide the college administration with valuable information on the curriculum’s strengths and weaknesses.

Similar to the findings of other studies, the first graduates perceived that the contents of ethics, professional, and behavioral sciences were the strongest in the curriculum.[5,6,7,8] Topics in medical ethics and human rights in medical curricula have been proposed by the World Medical Association since the year 1999[9] as they are crucial for the graduates’ professional practice. At the national level, the Saudi Commission for Health Specialties dictates that medical ethics should be taught in all medical institutions in the country.[10] “Professionalism,” which includes professional behavior and ethical principles, was recognized as a domain in the national competence framework (The Saudi Meds Framework).[11]

Teaching ethics and resolving ethical dilemmas in an educational setting is a complex endeavor owing to the context-dependent nature of medical ethics and the social dimensions of ethical issues. This is often less dependent on students’ knowledge and skills and more on an appropriate social environment and team approach.[10,12,13] Therefore, it is important for educational programs to have a continuous evaluation and improvement of the teaching of medical ethics in both undergraduate and postgraduate training.[8,12] A positive finding in the present study, revealed by the perception of its first batch of graduates, is that ethics, professional, and behavioral sciences were well addressed and properly taught in the reformed curriculum. Ethics and professional practice are the main aspects that underpin the mission and objectives of the College of Medicine. Moreover, many teaching and learning approaches in the reformed curriculum, such as PBL, CBL, and field exercises, are designed and contextualized with an emphasis on the importance of ethical, behavioral, and professional values.

In contrast, assessment and evaluation methods in terms of examinations and assignments were perceived as the weakest component of the reformed program. A finding of this nature is not uncommon as assessment methodologies in medical education continue to be the subject of many intense discussions as they have been widely criticized.[14] The low ranking of assessment methods reported is consistent with the findings of a study in which students considered assessment irrelevant, sometimes unfair, and often overlooked in relation to teaching and learning.[15] These findings are related to the fact that students might not fully understand how assessment decisions are made, for they only look at the serious, high-stakes implications of assessment results on their academic progression and future careers.[15] Therefore, students need to gain a better understanding of how assessments work and how to use assessment results to improve their own learning.[15] A case study on implementing an outcome-based education at Dundee Medical School emphasized that the assessment system should be designed to evaluate each student’s achievement of the learning outcomes for every academic year. Hence, learning outcomes, besides the course content, can establish a framework for designing assessment, a process referred to as blueprinting, and can also serve as a benchmark to evaluate the curriculum.[16] Therefore, assessment methods should align with course learning outcomes and be communicated to students through the blueprint. In addition, timely and regular feedback on assessment is crucial to support remediation and ongoing learning, and students should know the purpose of assessment and be assured of its quality.[17]

In the present study, there is a possibility that the first graduates of a reformed program may have difficulty adapting to the new curriculum and its various assessment methods, which could account for their low rating of assessment and evaluation methods. However, the perception on assessment methodology is central to any curriculum evaluation since it has a considerable influence on students’ approaches to learning and studying as well as their evaluation of the teaching faculty and curriculum content.[14,18] It is, therefore, necessary to conduct a further systematic evaluation for assessment practices at the College of Medicine.

The overall satisfaction scores given by the graduates for each academic year gradually increased from the 2^nd to the 6^th years. There was a steady trend in the students’ satisfaction in the first 3 years with a spiking increase in students’ satisfaction for the 5^th year. Lower scores were predicted in the 1^st years of medical school and particularly after implementing a reformed curriculum. Similar reports came from other medical schools.[5,8] Misimplementation and lack of experience of both faculty and students might lead to such a perception. These graduates were the first to enroll when the curriculum was first reformed, which could explain the improvement in their satisfaction with the later years as they adjusted to the new learning modalities. In the reformed MBBS program, there is no significant change to the curriculum of the later clinical years, which explains the higher satisfaction rates reflected by the graduates pertaining to the clinical years’ curriculum. Significant differences were observed between the 2^nd and 3^rd years, 2^nd and 5^th years, and 2^nd and 6^th years. The 3^rd and 4^th years were associated with a significant increase in the students’ satisfaction, with a peak in the 5^th year, which was not surprising as students’ satisfaction was found to increase with the increase in the interactive teaching and hands-on training compared to the lecture-based didactic learning.[19]

Regarding the graduates’ satisfaction and self-efficacy levels related to the academic program in terms of acquisition of knowledge and skills, the graduates gave the highest score to “the importance of teamwork and multidisciplinary work” followed by the acquisition of professional ethics. Both components had high rankings in similar studies.[5,6]

Pertaining to teamwork and multidisciplinary work, the same results were obtained from a review in which medical and healthcare graduates recognized the importance of teamwork in their inter-professional practice.[20] Teamwork principles, considered a critical component of medical education programs, can contribute to more effectiveness of the curriculum.[21,22] The importance of teamwork was also emphasized nationally as the Saudi Meds Framework identified “teamwork and inter-professional collaboration” among its associated competencies for Saudi medical graduates.[11] At the global level, the World Health Organization (WHO) emphasized the importance of a multidisciplinary team approach in medical practice.[22]

The high ranking of the knowledge of medical ethics is in line with previous findings that showed that 85% of medical students recognized the importance of ethical knowledge.[23] Another study found that most medical students were aware of and agreed with the importance of medical ethics in their professional lives.[24] Medical ethics is of prime importance and needs to be a part of the students’ routine practices.[23] Teaching medical ethics can enhance professionalism, competency, and moral quality.[24]

Amongst the self-efficacy components highly rated by graduates were medical history-taking and physical examination. This finding aligns with results from similar studies assessing the first graduates’ perceptions on a reformed medical curriculum.[5,6] Comparable results were reported about the perceptions of medical graduates on their preparedness for medical practice.[25] Similarly, in a 5-year literature review assessing graduates’ readiness for medical practice, the graduates perceived higher self-efficacy levels related to medical history-taking, physical examinations besides other clinical skills.[26] Collecting important information from the patient’s medical history is needed for effective clinical decision-making.[27]

An alarming finding that requires extra attention is the lowest scores of graduates’ self-efficacy given to the prescription of treatment. Comparable results were reported by two systematic reviews that highlighted insufficient competencies of final-year medical students and medical graduates to prescribe treatment safely and effectively.[25,26,28] In addition, respondents to another study reported a lack of learning opportunities and assessment on safe and effective drug use, together with little confidence in their ability to meet the competencies identified by the General Medical Council.[29] Consequently, the study highlighted a need to review undergraduate training on the safe prescription of treatment.[29] To improve prescribing skills in undergraduate medical education, formulating a list of recommendations with early clinical practice training was found to be useful.[30] In addition, introducing mechanisms such as feedback and reflection (using portfolios) may encourage graduates and junior doctors to reflect on their prescription practices and challenges, hence promoting their learning and enhancing patient safety and quality of healthcare.[31]

Finally, the present study showed that almost two-thirds of the respondents (67%) confirmed their readiness for the life of work as interns and residents. This result is compatible with the views of the first two cohorts who graduated from a reformed curriculum.[3] In addition, most of the graduates in the present study (81.4%) revealed that they were proud to be doctors in the same way shown by a similar study.[5] These findings are considered positive indicators that reflect the first graduates’ approval of the newly reformed MBBS program at the College of Medicine.

There are some limitations in the current study. The low response rate made it difficult to gather information from students after graduation, especially as they were scattered across multiple locations. The response can hardly represent the whole batch of the first graduates. The lack of qualitative data support can also be viewed as a limitation. In addition, evaluating courses after graduation, especially those taught in the basic science courses, may have led to recall bias. Including qualitative data from open-ended questions could further enhance the graduates’ perception levels. Furthermore, the study examined perceptions rather than actual skills and competencies of the graduates, and therefore over or underreporting could have occurred.

Conclusion

This study has explored the perception of the first graduates on the efficacy of the reformed MBBS program as well as their satisfaction and self-efficacy levels on the acquired knowledge and skills. The graduates’ positive opinions pertaining to the efficacy of the reformed curriculum were considered supportive reflections. The study’s findings present valuable information for potential curriculum revision and improvement. Further internal studies are needed to examine how to better integrate the basic science content and improve the assessment and evaluation methods. In addition, future qualitative studies can explore the perceptions of the graduates in greater detail to determine how the curriculum design can be improved. Maintaining continuous contact with graduates is essential for the evaluation of their professional performance. Future studies should also compare the performances of the graduates with graduates from other medical colleges and identify ways of improving different aspects of the MBBS program.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.