Family medicine residents’ perspectives on different teaching modalities used throughout their training

ABSTRACT

Background:

New teaching modalities have emerged throughout the years to help enhance residency training programs. Studies have shown that when establishing a new teaching modality, it is crucial to consider the trainee’s perception and feedback as trainee-centered teaching techniques aim to enhance the students’ motivations and problem-solving skills. The aim of this study is to discover residents’ perceptions of different teaching modalities used through their training programs and to recognize which teaching modality is preferable to residents among the family medicine residents in Riyadh, Saudi Arabia.

Methodology:

A cross-sectional study was conducted between April 2021 and April 2022 that included all family medicine residents in the Saudi Board Family Medicine Training Program at Prince Sultan Military Medical City (PSMMC) in Riyadh, Kingdom of Saudi Arabia. An online questionnaire included two main parts. The first part collected demographic information. The second part concerned residents’ opinions regarding different teaching modalities used throughout their training and factors leading to better learning outcomes.

Results:

The survey was completed by 60 family medicine residents. Half of the respondents perceived weekly academic day activities [WADA] as the most important teaching style (53.3%), followed by self-directed learning [SDL] (40%), while learning management system [LMS] was not ranked as the top choice by any of the respondents.

Conclusion:

These findings can be applied to the improvement of family medicine training programs. Understanding the perceptions of different teaching modalities can help enhance training programs to help future family medicine practitioners.

Introduction

Family medicine is an academic and scientific discipline that focuses on the continuity of care with its own educational content, research, evidence bases, and clinical activity.[1] It is a comprehensive clinical specialty oriented to primary care and not limited to a certain gender, age group, or one organ system.[1,2] High levels of burnout have been widely reported among postgraduate medical trainees. However, relatively little literature has examined family medicine residents’ well-being.[3,4] In recent years, fewer medical school graduates have entered primary care specialties, despite the great need worldwide. High rates of burnout during residency, relatively poor quality of life, and family physicians saying they would choose a different specialty if possible are likely contributors.[4]

Developed countries are leaning more toward the use of new teaching techniques that are mostly student-centered, and in Saudi Arabia, there has been a simultaneous increase in interest in medical education and a rapid expansion of the number of medical schools and training programs.[5,6] Despite the great advances in medical education, the process of delivering medical information to postgraduate trainees remains unchanged, relying primarily on didactic lectures.[7] Student-centered teaching techniques aim to enhance students’ motivation and problem-solving skills. Studies have shown that, when establishing a new teaching modality, it is crucial to consider the trainee’s perception and feedback, as it is shown to have a tremendous improvement in their performance.[8,9]

Some new teaching modalities have emerged throughout the years, including self-directed learning (SDL), case-based discussions (CBD), learning management systems (LMS), and weekly academic day activities (WADA).[10,11] The trainee’s perception and feedback regarding the updated teaching methods are not usually considered. To our knowledge, lack of studies in the literature has investigated residents’ perspectives toward the use of different educational modalities in Saudi Arabia. As a result, there is a strong justification for conducting research on perception and feedback for different teaching methods. The aim of the study is 1) to explore residents’ perceptions of different teaching modalities used through their training and 2) to identify which teaching modality is preferable to the residents among family medicine residents at Prince Sultan Military Medical City (PSMMC) in Riyadh, Saudi Arabia.

Research Methodology

Study design: A cross-sectional study was conducted between April 2021 and April 2022.

Study setting: Prince Sultan Military Medical City (PSMMC) in Riyadh, Kingdom of Saudi Arabia.

Population: All family medicine residents (n = 87) in the Saudi Board Family Medicine Training Program.

Data collection: Participation was voluntary, and written informed consents were obtained before the study. The survey was completed by 60 out of 87 family medicine residents, with a 68.97% response rate.

Study plan: The study was carried out in accordance with the code of ethics of the Declaration of Helsinki for humans. Institutional review board approval was obtained in advance by the ethics and research committee of Prince Sultan Military Medical City (PSMMC) in Riyadh, Saudi Arabia. Informed consent was obtained from all participants.

Data management and statistical study: The questionnaire included two main parts. The first part collected information on age, gender, marital status, and residency level. The second part was residents’ opinions regarding different teaching modalities used throughout their training (weekly academic day activities [WADA], case-based discussion [CBD], learning management system [LMS], self-directed learning [SDL], and research course) and factors leading to better learning outcomes. It assessed by use of five Likert-scale items on a scale from 1 (“Strongly Agree”) to 5 (“Strongly Disagree”). The questionnaire was developed based on the international literature and was validated using expert opinions from three different family medicine consultants and tested for reliability.

Statistical analysis was performed using R version 3.6.3. Counts and percentages were used to summarize categorical variables. The mean ± SD and the median/interquartile range (IQR) were used to summarize the continuous normal and non-normal variables, respectively. One-way analysis of variance (ANOVA) was used to assess the association between residency level and the perception of different learning methods.

Spearman’s correlation was used to assess the association between continuous variables. The Chi-square test of independence was used to assess the association between categorical variables. Principal components analysis (PCA) was used to capture the variance in the responses provided for each teaching method to reduce the number of dimensions and facilitate interpretation of the results. The score for each component was calculated by averaging the scores for the corresponding items. Hypothesis testing was performed at a 5% level of significance.

Results

The study sample included 60 residents (58.3% males and 41.7% females). Respondents aged 25 to 30 represented most of the samples (91.7%). R2 residents accounted for less than half of the sample (41.7%), and R3 residents represented 26.7%. R4 and ex-R4 residents represented 21.7% and 10%, respectively [Table 1].

Table 1.

Descriptive statistics for the study sample

	[ALL] n=60	n
Age:		60
20–25 years old	2 (3.33%)
25–30 years old	55 (91.7%)
>30 years old	3 (5.00%)
Gender:		60
Female	25 (41.7%)
Male	35 (58.3%)
Residency level:		60
Ex-R4	6 (10.0%)
R2	25 (41.7%)
R3	16 (26.7%)
R4	13 (21.7%)
Marital Status:		60
Divorced	2 (3.33%)
Married	20 (33.3%)
Single	38 (63.3%)

The results in Figure 1 show that 65% of the residents agreed/strongly agreed that the previous experience as a WADA presenter improved their presentation skills, and ~75% agreed/strongly agreed that the WADA activities improved their knowledge. Approximately one-third of the residents agreed that attending WADA sessions should be optional, and ~50% agreed/strongly agreed that WADA activities promote interaction.

Figure 1.

Perception regarding the WADA (1 = strongly agree; 5 = strongly disagree)

The results show that the WADA responses could be collapsed into two components. Component 1 (RC1) included eight items related to perceived satisfaction regarding WADA, while items 9 and 10 were related to the importance of attending WADA sessions. Thus, the scores for the first eight items were averaged to create a composite score that can be used for further analysis. Items 9 and 10 were treated as individual items, as they did not load with the remaining items and had a low correlation [Table 2].

Table 2.

Principal component analysis (PCA) of the WADA items

Principal Component Analysis
	Perceived benefit of WADA	WADA teaching style
My previous experience as a WADA presenter improved my presentation skills	0.93	-0.07
My previous experience as a WADA presenter improved building self-confidence	0.94	-0.15
The experience with the previous WADA the supervisor was beneficial in terms of scientific guidance	0.92	-0.11
The experience with the previous WADA the supervisor was beneficial in terms of the organization of slides	0.77	0.10
The WADA presentation topics cover the curriculum	0.83	-0.10
The WADA activities improve the knowledge	0.84	0.01
The WADA activities improve the clinical/practical skills	0.60	0.17
WADA activities promote interaction	0.60	0.30
Having virtual WADA activity is preferred	-0.01	0.82
Attending WADA sessions should be optional	-0.21	0.90
Cronbach’s α	0.93	0.62

Results showed that ~50% of the residents agreed/strongly agreed that the CBD feedback was effective and made a change with the practice. Approximately 40% of the respondents agreed/strongly agreed that the previous feedback was constructive and specific. Three-quarters of the respondents agreed/strongly agreed that verbal feedback was preferred to written feedback and that a preplanned CBD is preferred to prepare for it. Responses regarding the use of virtual CBD were split [Figure 2]. The PCA analysis of CBD items is given in Table 3. Two CBD components were identified using PCA. Component 1 mainly included items related to the perceived benefit of CBD, while component 2 included items related to teaching style.

Figure 2.

Perception regarding the CBD (1 = strongly agree; 5 = strongly disagree)

Table 3.

PCA analysis of CBD items

Principal Component Analysis
	Perceived benefit of CBD	CBD teaching style
CBD sessions helped improve discussion skills	0.81	-0.05
The experience with the CBD supervisor was beneficial in terms of scientific guidance	0.91	-0.10
The previous feedback was specific enough	0.95	-0.02
The previous feedback was constructive	0.88	0.04
The previous feedback was effective and made a change in the practice	0.86	0.09
Verbal feedback in person is preferred to written feedback on LMS as it gives more room for discussion	0.06	0.77
Verbal feedback in person is preferred to written feedback on LMS because it is more personal and individualized	-0.15	0.92
A pre-planned CBD is preferred to prepare for it	0.13	0.80
Cronbach’s α	0.93	0.78

The responses showed a conflicting attitude toward the LMS. Regarding the content, 41.7% were indecisive regarding whether the content on the LMS module was neutral. However, ~50% agreed/strongly agreed that the content is relevant to the curriculum. One-third of the residents strongly agreed that the LMS helps keep track of assignment submissions. One-half of the residents strongly agreed that reviewing topics in the LMS module should be optional [Figure 3]. PCA showed that two components explained 71% of the variance in all seven items. Component 1 included four items relevant to the content of the LMS, and component 2 included three items related to LMS usefulness [Table 4].

Figure 3.

Perception regarding LMS (1 = strongly agree; 5 = strongly disagree)

Table 4.

PCA analysis of LMS items

Principal Component Analysis
	Usefulness of LMS content	Usefulness of LMS platform
The content on the LMS modules is relevant to the curriculum	0.81	0.07
The content on the LMS modules is excellent	0.92	-0.06
Having an online system with due dates helps keep track of assignments submission	-0.01	0.85
Having a pre-class material on LMS to review before attending WADA activity facilitates the understanding during WADA activity	0.79	0.16
Reviewing topics on the LMS module and solving quizzes before attending the WADA activity should be optional	-0.09	0.87
LMS is mostly used to review weekly modules	0.11	0.73
Other programs/specialties should implement the same system	0.88	-0.14
Cronbach’s α	0.87	0.76

Regarding research activities, half of the respondents (53.3%) agreed/strongly agreed that the research course would help in a future career, and one-third (35%) strongly agreed that regular assignments help in writing a whole research proposal. Approximately half of the respondents were satisfied/strongly satisfied with the research course structure. Approximately one-third of the respondents were neutral. PCA analysis showed that one component explained ~70% of the variance in the seven items [Figure 4].

Figure 4.

Perceived usefulness and satisfaction with research course (1 = strongly agree; 5 = strongly disagree)

The results show that the percentage of residents who strongly agreed range from 40% to 60%, with an overall agreement (strongly agree/agree) ranging from 60% to 80%. PCA analysis showed that one component explained ~80% of the variability in all three items [Figure 5]. Half of the respondents perceived WADA as the most important teaching style (53.3%), followed by SDL (40%), while LMS was not ranked first by any of the respondents. LMS was ranked the fourth by 63.3% of the respondents [Figure 6].

Figure 5.

Perceived usefulness of self-directed learning (1 = strongly agree; 5 = strongly disagree)

Figure 6.

Ranking of different teaching methods

Regarding the association between residency level and component scores, a statistically significant positive association was observed between the perception of WADA and the perception of CBD benefit, perception of SDL benefit, preference for verbal feedback, the usefulness of LMS content, the usefulness of the LMS platform, and the usefulness of the research course (P < 0.001). The usefulness of the research course was associated with the usefulness of research content (P < 0.05), perception of self-directed learning (P < 0.001), and perceived usefulness of the LMS platform (P < 0.001) [Table 5].

Table 5.

Association between residency level and component scores

	R2 n=25	R3 n=16	R4 n=13	Ex-R4 n=6	P
Perceived WADA benefit	2.44 (0.84)	2.85 (1.16)	2.56 (0.84)	2.33 (0.76)	0.509
Perceived CBD benefit	2.55 (0.99)	2.79 (1.03)	2.72 (0.90)	3.23 (1.11)	0.503
Preference for verbal feedback and prior preparation	2.17 (0.95)	2.40 (1.15)	2.21 (0.91)	1.94 (1.02)	0.802
Perceived CBD benefit	2.66 (0.99)	3.19 (0.93)	3.06 (1.08)	3.25 (1.27)	0.328
Preference for verbal feedback and prior preparation	2.44 (1.16)	2.62 (1.22)	2.26 (0.71)	2.33 (1.45)	0.842
Usefulness of research course	2.51 (0.97)	2.76 (1.12)	2.86 (1.03)	2.38 (1.36)	0.696
Self-directed learning	1.95 (1.06)	2.23 (1.19)	1.69 (0.92)	2.00 (1.56)	0.648

Analysis was performed using one-way ANOVA

Discussion

There is a lack of papers in the literature discussing trainer’s perception and feedback regarding the updated teaching methods. To our knowledge, this is the first study to assess this matter in family medicine residents in the region and Saudi Arabia. The study sample included 60 residents (58.3% males and 41.7% females). Half of the respondents perceived WADA as the most important teaching style (53.3%), followed by SDL (40%), while LMS was not ranked first by any of the respondents. Our results show that junior resident prefer WADA followed by SDL as their best teaching methods. Most of the residents agreed/strongly agreed that the previous experience as a WADA presenter improved their presentation skills, and ~75% agreed/strongly agreed that the WADA activities improved their knowledge. Responses regarding the use of virtual CBD and LMS were split. Results showed that ~50% of the residents agreed/strongly agreed that the CBD feedback was effective and made a change with the practice. 41.7% were neutral regarding whether the content on the LMS module was neutral, and ~50% agreed/strongly agreed that the content is relevant to the curriculum. Regarding research activities, approximately half of the respondents were satisfied/strongly satisfied with the research course structure and agreed/strongly agreed that the research course would help in a future career.

A cross-sectional analytical study discussed family medicine residents’ perceptions of mandatory half-day activities as a part of the Board Program. The results showed that 72% of the respondents were eager to attend the WADA, and 55% were excited to attend upcoming activities.[12] In our study, the respondents perceived WADA as the most important teaching style and that it helped them improve their presentation skills. In addition, a statistically significant positive association was observed between the perception of WADA and the perception of CBD benefit, perception of SDL benefit, preference for verbal feedback, the usefulness of LMS content, the usefulness of LMS platform, and the usefulness of the research course. Another study that evaluated different assessment and teaching methods used in a pharmacology school found that most students rated revision sessions as the most useful teaching method, and tutorials were rated as good to very good by the majority of the students, while lectures had a very limited role in their learning experience. Students suggested that more interactive lectures be given by the faculty.[8]

In 2018, Kathryn A. Holmes et al.[13] aimed to compare the faculty and students’ perspectives on the learning management system (LMS) as an implemented teaching method. The study focused on the elements that enhanced interactivity as well as the elements enabled accessibility from the perspective of both the staff and students. Most students agreed that LMS quizzes and tests enhanced interactivity during sessions, while having LMS blogs was the least useful method to enhance interactivity during the sessions. Also, students agreed that having the documents on the LMS was extremely effective followed by the videos provided by the lecturers. However, it was noted that the students’ attendance decreased significantly due to the availability of the documents online. Another study focused on a type of open-source learning management system, “Moodle,” and compared it to a group that received PDF files only. The results showed significant improvement in the level of knowledge of trainees who used the online learning module before the start of their clinical rotations. The study had a small sample size, which is a limitation of the study. It also targeted the gain of short-term knowledge.[14] However, studies have shown that the blended learning method has a significantly positive outcome when compared to the traditional teaching method alone. Students who were taught using the blended method gained more critical thinking skills, more clinical skills, and better knowledge.[15] Web-based learning (WBL) as a teaching technique was studied in a randomized clinical trial among medical residents. The results showed no significant difference in the knowledge level when compared to the traditional method. However, the time spent using WBL in learning was 18% less than the traditional way of teaching. Most residents (75%) preferred the use of the WBL method in their clinical training.[16]

Problem-based learning (PBL) in teaching is one of the most commonly used tools. Studies have shown that students scored higher using the PBL technique when compared to the traditional method. The students agreed that the PBL method helped them acquire further clinical knowledge. Furthermore, the students unanimously agreed that the traditional method was considered a barrier when it came to student interaction and discussion, which were extremely helpful to the students when being taught using the PBL method. A comparative study assessed the perception of PBL and traditional teaching methods. The results showed that the PBL teaching method was, in general, perceived by the students to be superior to the traditional teaching method. “Peer communication” in the PBL sessions came back as the highest perceived factor, followed by self-challenging by critical thinking, while it was “Adequacy of Teaching” that came back as the highest perceived factor in the traditional teaching method.[17] Wanjun Zhao et al.[18] evaluated the effectiveness of combining two different teaching methods: problem-based learning (PBL) and case-based learning (CBL). Using the PBL-CBL method in the assigned group, another exam was given after class, which showed that the PBL-CBL group had significantly better results compared to the group that was only taught in class using the traditional teaching method. The study showed that the use of PBL-CBL as a teaching method in medical school or residency programs can enhance the trainee’s understanding capability, critical thinking skills, communication skills, and clinical thinking.

Lack of a protected time to pursue academic interests and research was shown in the literature to be one of the most common factors linked to burnout.[19] In our study, approximately half of the respondents were satisfied with the research activities and agreed/strongly agreed that the research course would help in a future career. This may be because most of the residents in medical schools in Saudi have had a protected time for research activities, as it shown that the majority of Saudi medical schools are implementing research methodology courses in their undergraduate curricula.[20] Also, another point that was raised in the literature that was shown to be a great helper to enhance learning experience and decrease burnout was having a good relationship with a mentor.[21]

Limited studies in the literature have investigated residents’ perspectives on the use of different educational modalities. Our study adds to the literature about the perceptions of different teaching modalities used through training as family medicine residents in Saudi Arabia. The limitations of our study include 1) its cross-sectional design, which is incapable of evidencing causation, and 2) its small sample size, which is another limitation, despite a good response rate. Understanding the perceptions of different teaching modalities can help enhance training programs to help future family medicine practitioners.

Conclusion

The respondents perceived WADA as the most important teaching style, followed by SDL. Most of the residents agreed that their experience as WADA presenters improved their presentation skills and improved their knowledge. Half of the residents agreed that the CBD feedback was effective and helped with the practice. Approximately half of the respondents were satisfied with the research course and agreed that it would help in a future career. A statistically significant positive association was observed between the perception of WADA and the perception of CBD benefit, perception of SDL benefit, preference for verbal feedback, the usefulness of LMS content, the usefulness of the LMS platform, and the usefulness of the research course. This study concluded that WADA was the most preferred modality it terms of improving the residents presentation skills and knowledge, thereby it should be used as a main teaching method. A further attention should be directed toward improving the LMS platform to meet the residency objectives. We suggest future research which covers a larger sample size in multi-residency programs.

Declaration

The study was carried out in accordance with the code of ethics of the Declaration of Helsinki for humans. The study was approved by the ethic and research committee of the ethic and research committee of Prince Sultan Military Medical City (PSMMC) in Riyadh, Saudi Arabia. Informed consent was obtained from all the participants. All authors have confirmed the submission and that this study did not involve animal subjects or tissue.

Authors’ contributions

All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship and approved the final manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.