Building the 8-star doctor: a modified Delphi study to define, teach, and assess health professions education for undergraduate medical students

Abstract

Background

As global trends in medical education shift toward integrated curricula, there remains a lack of consensus on the core components of Health Professions Education (HPE) to be embedded within undergraduate medical programs. This study aims to identify and structure key HPE topics relevant to the MBBS curriculum, with the goal of enhancing students’ foundational competencies in teaching, leadership, and professionalism. It also seeks to propose appropriate pedagogical approaches and assessment strategies for effective curricular integration.

Methods

A multi-phase, mixed-methods study design was employed. The initial phase involved a comprehensive literature review, followed by expert consensus through the Nominal Group Technique (NGT) with 19 national HPE professionals. This was succeeded by a three-round modified e-Delphi process involving 69 HPE experts across Pakistan. Participants rated the importance of proposed content items using a three-point Likert scale. Topics achieving ≥ 80% consensus were retained. The stability of responses across rounds was assessed using McNemar’s test. Teaching methodologies and assessment tools were finalized in the third round.

Results

The NGT process streamlined 54 initial content items to 37, eliminating 12, modifying 5, and adding 2 new topics. The Delphi process led to consensus on 17 key items, including bedside teaching, procedural skills, leadership, communication, professionalism, medical ethics, and patient safety. Preferred teaching strategies included small-group discussions (SGD) and large-group interactive sessions (LGIS), both receiving over 50% expert agreement. Objective Structured Teaching Exercises (OSTE) emerged as the most endorsed assessment approach. Response rates for the three Delphi rounds were 93%, 96%, and 90%, respectively.

Conclusion

This study presents a consensus-driven framework for the integration of HPE into undergraduate medical curricula. The findings underscore the relevance of structured teaching, evidence-based learning strategies, and pragmatic assessments. The framework has potential applicability for scalable curricular reforms in five-year undergraduate medical programs globally.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07694-7.

Introduction

Every doctor teaches—whether consciously or not. The term doctor is derived from the Latin docere, meaning “to teach,” highlighting the intrinsic link between medicine and education [1]. Beyond clinical care, physicians are responsible for fostering a culture of learning by mentoring peers, educating patients, and contributing to academic discourse [2]. Despite this integral role, many undergraduate medical programs worldwide lack a structured curriculum that formally prepares students with essential teaching competencies.

The concept of the 7-star doctor, as endorsed by the World Health Organization (WHO) [2, 3], includes the roles of care provider, decision-maker, communicator, community leader, manager, life-long learner, and researcher. However, with the evolving demands of healthcare systems and academia, there is increasing recognition of an eighth role: the teacher. Adding the “teacher” role acknowledges the responsibility of every physician to contribute to the education of peers, junior learners, and interprofessional colleagues.

Teaching intersects with nearly all listed competencies, whether through patient education, interprofessional collaboration, or scholarly dissemination [4]. Nonetheless, the act of teaching often remains an implicit expectation, rather than a formally cultivated skill in undergraduate curricula [5, 6]. International educational frameworks such as the World Federation for Medical Education (WFME) global standards [7], the CanMEDS framework, and the UK’s Tomorrow’s Doctors similarly acknowledge the importance of teaching in medical practice. However, they often treat it as an assumed attribute rather than a standalone, assessable competency (Fig. 1). This oversight risks producing graduates who are ill-equipped to meet the pedagogical demands of clinical environments [7, 8].

Fig. 1.

Frameworks from literature emphasizing health profession education’s significance

Further complicating the issue is the global variability in medical curricula. For example, U.S. medical schools often include student-as-teacher (SaT) programs as part of elective or formal coursework [9, 10]. While many institutions in other regions continue to rely on traditional, didactic, teacher-centered models [9]. A review of 39 undergraduate Health Professions Education (HPE) programs revealed wide variability in content and delivery, underscoring the absence of a standardized, evidence-informed framework [11]. The lack of curricular alignment between what to teach, how to teach, and how to assess highlights a critical gap in medical education [12].

Adding the “teacher” role acknowledges the responsibility of every physician to contribute to the education of peers, junior learners, and interprofessional colleagues. The transition from the 7-star to the 8-star model reflects a natural evolution in medical identity, particularly as medical graduates are often expected to teach during internships and residency, frequently without formal preparation.

Equipping medical students with teaching skills offers multiple benefits. It enhances learning through the “learning by teaching” model, prepares students for teaching roles during residency, and strengthens professionalism, communication, and feedback delivery. Early exposure to teaching also supports long-term faculty development crucial in settings with faculty shortages. International programs have shown that structured teaching curricula improve student confidence, professionalism, and reflective practice [5, 6, 13].

This study supports the 8-star model by offering an evidence-informed framework to equip students with foundational educational competencies during undergraduate years, thus ensuring readiness for teaching roles at every career stage. The study adopts Lattuca and Stark’s curriculum development framework [14, 15] to design an integrated, contextually relevant model for embedding HPE content into undergraduate medical education. This approach aims to identify essential topics, align them with appropriate teaching strategies and assessment tools, and provide a practical roadmap for curricular integration (Fig. 2).

Fig. 2.

Lattuca and starks curriculum development framework

Methods

This study followed a systematic, multi-phased approach to develop, refine, and validate HPE framework for the MBBS curriculum (Fig. 3).

Fig. 3.

Phases of the study to determine learning content of HPE along with its teaching modalities and assessment methods

Phase I: literature review

A comprehensive literature review was conducted using databases such as Google Scholar, PubMed, Scopus and Web of Science focusing on terms like “student as teacher program,” “medical education” “health profession education”, “learning by Teaching “, “teach to learn”, “learn to teach” and “health professions education.” The review identified 54 potential HPE topics, categorized domains based on the CanMEDS framework.

Phase II: nominal group technique (NGT)

The identified topics were refined using the NGT. Nineteen medical education experts were selected based on minimum criteria of at least 2 years’ experience in curriculum designing, teaching and student assessment in an integrated curriculum. During a 90-minute virtual session, experts provided feedback, ranked items, and reached consensus [16, 17] (Additional file 1, Appendix A).

Phase III: modified Delphi study

Delphi expert panel selection

Purposive sampling was used to select 69 experts from all provinces of Pakistan, ensuring diverse representation [18]. Inclusion criteria required participants to have postgraduate qualifications (e.g., MHPE or PhD in HPE) and at least two years of teaching experience (Table 1).

Table 1.

Characteristics of Delphi participants

Characteristics	Frequency n (%)
Designation
Professor	19 (29.6%)
Associate Professor	6 (9.4%)
Assistant Professor	21 (32.8%)
Lecturer	6 (9.4%)
Others	12(18.7%)
Department Medical Education	64 (100%)
General Education	0
Gender Female	40 (62.5%)
Male	24 (37.5%)
Degree in Medical Education Diploma	12 (18.8%)
MCPS-HPE	4 (6.3%)
MHPE	42 (65.6%)
PhD Health Profession Education	6 (9.4%)
Experience
More than 20 years	6 (9.4%)
More than 10 years	27 (42.2%)
5–10 years	15 (23.4%)
Less than 5 years	16 (25.0%)
Teaching Capacity in Medical Education
Full-Time Faculty	37 (57.8%)
Part-Time Faculty	17 (26.5%)
Visiting Faculty	07 (10.9%)
Not Working at the Movement	03 (4.6%)
Province
Sindh	20 (31.3%)
KPK	17 (26.6%)
Punjab	14 (21.9%)
Islamabad	9 (14.0%)
Baluchistan	4 (6.2%)

The Delphi rounds

The questionnaire developed after literature review and nominal group was used in Delphi rounds (Additional file 1, Appendix B). Delphi method is a consensus-building approach, favoured for its ability to maintain expert anonymity and free expression. Decisions are made by the majority, and experts can adjust their responses based on group feedback [19, 20]. A three-round Modified e-Delphi process was conducted to achieve consensus (Fig. 4) (Additional file 1, Appendices C & D).

Fig. 4.

Three-round modified Delphi

Data analysis

Survey responses were collected using a secure online platform, ensuring participant anonymity to minimize response bias.

Quantitative analysis

1. Consensus levels were assessed based on percentage agreement.

2. McNemar’s test was used to evaluate response stability across rounds.

3. Items meeting the ≥ 80% agreement threshold were included in the final curriculum framework.

McNemar’s test was selected to assess response stability between Delphi rounds for items re-circulated due to lack of consensus. It is a non-parametric test suitable for paired nominal data, and widely used in Delphi research to detect significant shifts in dichotomous responses across rounds. In this study, McNemar’s test helped confirm data saturation and decision stability after Round 2, justifying closure of consensus on those items. This methodological transparency enhances the rigour of the consensus process [21].

Qualitative analysis

The qualitative insights were captured through open-ended responses and expert comments during Delphi rounds and the Nominal Group Technique (NGT) session. These data were used to inform item rephrasing, topic refinement, and consensus discussion, rather than to generate new conceptual themes. The analysis followed a content-informed iterative approach, where expert feedback was:

• Reviewed by the core research team,

• Mapped against existing literature and framework domains,

• Utilized for item modification, rephrasing, or clarification.

This pragmatic approach is consistent with modified Delphi studies where qualitative input serves a supportive, not primary, analytical role, especially when the aim is consensus development and item validation rather than grounded theory building or inductive thematic exploration [22, 23].

Results

Refinement of HPE topics

From an initial 54 topics, the NGT process refined the list to 37 items by: (1) Eliminating 12 redundant items, (2) Rephrasing 5 items for clarity and (3) Adding 2 new items based on expert feedback. These 37 topics were categorized into five core themes (Fig. 5):

Fig. 5.

The core themes of Learning Content of HPE

Delphi rounds

A three-round Modified e-Delphi process was conducted to achieve consensus. Table 2 shows the content introduced in round 1 and not tested for stability. Table 3 shows the summary of three Delphi rounds.

Table 2.

Content introduced in round 1 and not tested for stability

Items suggested by experts in round 1 but not tested for stability
Learning content	Percentage response	Reason for elimination
Long-term, intermediate, and short-term memory	60	The consensus is less than 80%. “Long term, Intermediate and short-term memory: it is already included in MBBS syllabus, in neurosciences.”
Spiral curriculum	50	Percentage agreement falls in the plurality range (50% or less) Expert response “spiral curriculum, a type of curriculum-which has been included in “Basics of curriculum and its various types.”
Study guide, TOS, and blueprinting	60	The consensus is less than 80%. “These are more important for the teachers, not for the students.” “More relevant to the teachers and applied to students.”
Online assessment	40	Percentage agreement falls in the plurality range (50% or less) “Not important as we have inferior net connectivity and residence of our students are far away from the Quetta city where online classes and assessment are not possible due to lack and/or poor net connectivity.” “Due to unavailability/ poor net connection, we cannot conduct online classes and assessments. Our students have complained about a lack of internet connectivity or frequent net cut-off during COVID-19. Most students live in remote areas where the net assessment is impossible. Therefore, neither online teaching nor online exams are possible in these circumstances. That is why I do not favour online classes or assessment.”

Table 3.

Summary of results of three Delphi rounds

Domain	Content	Teaching Strategy (With maximum Response	Assessment Method (with maximum response)
Educational Psychology	1. Self-Directed Learning	LGIS	MCQ
Teaching & Learning	1. Beside Teaching	Student presentation SGD	OSTE
	2. Procedural Skill Teaching	Skill Lab	OSTE
	3. Simulation Learning	SGD	OSTE
	4. Skill for delivering an effective presentation	Student Presentation	OSTE
Assessment	1. Assessment of Skill	Workshop	Reflective Portfolio
	2. Assessment of Attitude	Small Group Discussion	OSTE
	3. Providing Feedback	Student Presentation	Reflective Portfolio
	4. Reflection & Reflective Writing	SGD	Reflective Portfolio
Leadership & Professionalism	1. Research and Scholarship	LGIS	Assignment
	2. Critical Thinking & Problem Solution	PBL	Short Answer Questions
	3. Interpersonal & Communication Skills	Workshop Role Play	Multisource Feedback OSTE
	4. Leadership and Leading Clinical Teams	LGIS	Reflective Portfolio
	5. Medical Ethics	LGIS	MCQ
	6. Patient Safety & Quality Care	LGIS	MCQ
	7. Professionalism & Medical Care	LGIS SGD	Reflective Portfolio
	8. Stress Management	Workshop	Multisource Feedback

*SGD: Small Group Discussion, LGIS: Large Group Interactive Session, PBL: Problem Base Learning, OSTE: Objective Structured Teaching Exercise, MCQ: Multiple Choice Question

Delphi consensus outcomes

At the end of three Delphi rounds, 17 items were finalised (Fig. 6).

Fig. 6.

Results of three-round modified e-Delphi

Preferred teaching and assessment strategies

Out of multiple strategies, few were selected based on expert consensus (Fig. 7).

Fig. 7.

Teaching strategies and assessment methods

Teaching methods

Large-group interactive sessions (LGIS): 50% consensus.

Small-group discussions (SGD): Emphasized for experiential learning.

Assessment methods

Objective Structured Teaching Exercises (OSTE): Highest agreement (33%).

Reflective portfolios: Highlighted for assessing professionalism.

Qualitative insights

Experts emphasized the importance of Educational Psychology in fostering lifelong learning. Participants noted that “teaching and learning are often underestimated in developing countries” and recommended incorporating feedback-based assessment in undergraduate education.

Discussion

Efforts by the World Federation for Medical Education (WFME) have increasingly emphasized the need to transition from traditional, didactic curricula toward student-cantered, lifelong learning. Strategies such as case-based learning, bedside teaching, and interprofessional education are now central to modern medical education. Despite global progress in defining undergraduate learning objectives, considerable variability persists in how teaching content is implemented and prioritized across programs [24].

Although the importance of teaching as a professional competency is well established, it remains underrepresented in many undergraduate medical curricula. Often relegated to elective modules or student-selected components, teaching is not formally recognized as a core skill [25–27]. While international studies have identified relevant learning objectives for undergraduate Health Professions Education (HPE) [10], considerable heterogeneity persists in terms of content, delivery, assessment methods, and structural format [6, 24]. The integration of new subjects such as HPE into medical curricula poses challenges related to curricular overload, faculty readiness, institutional resources, and competing priorities [26].

This study reinforces the necessity of embedding HPE content especially teaching, leadership, and professionalism into the undergraduate curriculum. Through a multi-phase consensus process, 17 key topics were identified that bridge both clinical and non-clinical competencies. Topics such as bedside teaching, procedural skills, and communication are strongly aligned with global competency frameworks like CanMEDS, affirming their relevance in diverse educational contexts [2]. However, cognitive domains such as curriculum design and learning theories did not reach consensus. Experts noted that including such content might contribute to cognitive overload and may not yield immediate practical benefits in already content-heavy curricula [28, 29]. These observations highlight the need to balance conceptual knowledge with hands-on competencies.

The results further demonstrate that competency-based learning, combined with student-centred teaching strategies and structured assessments, supports the development of critical thinking, leadership, and professional identity. Unlike conventional curricula that focus primarily on biomedical knowledge, the proposed framework prioritizes non-clinical domains such as patient safety and professionalism, addressing existing gaps in competency-based medical education (CBME) models [8. 10].

Student resistance to curricular integration of cognitive topics has been previously reported and often stems from preference for traditional methods or perceived content burden [28, 29]. Our findings echo these concerns, underscoring the importance of integrating experiential learning with cognitive scaffolding to enhance engagement and knowledge retention.

Core learning content: competencies for the modern physician

Leadership, patient safety, and professionalism emerged as essential competencies for contemporary medical practice. Despite broad endorsement, their implementation in undergraduate programs remains inconsistent. However, the inclusion of these competencies is supported by a substantial body of literature. Passi and Johnson [30] emphasized that Student as Teacher (SaT) progra ms must include modules on communication, professionalism, and feedback to ensure students are equipped for formal educational roles. A scoping review by Burgess et al. [25] concluded that internationally developed SaT curricula frequently incorporate these components, citing them as standard practice for safe and effective student-led instruction. The CanMEDS Physician Competency Framework (2015) also identifies Communicator, Professional, and Leader as key roles applicable to both clinical and educational settings [31].

While clinical teaching components received widespread support, certain topics such as online assessments and spiral curricula did not achieve consensus. Contextual factors including limited technological infrastructure, faculty preparedness, and institutional constraints were cited as barriers. These results suggest that while core content can be standardized, implementation strategies must remain adaptable to local contexts.

Preferred teaching strategies: emphasis on active learning

Student-centred pedagogies were clearly favoured, with small group discussions (SGDs) identified as the most effective modality, particularly for clinical subjects requiring observation, feedback, and reflective engagement [13, 32]. SGDs promote deeper understanding, collaboration, and professional development, aligning with global best practices.

Large-group interactive sessions (LGIS), although less preferred, were recognized for their practicality in resource-constrained settings. These sessions facilitate broad content delivery and can support professional identity formation through exposure to the hidden curriculum. (33)

Participatory models such as case-based learning (CBL), problem-based learning (PBL), and interprofessional education (IPE) have been widely acknowledged for enhancing retention and application of knowledge [33]. Student presentations, peer teaching, and feedback-driven formats were also valued for fostering motivation, confidence, and deeper conceptual understanding.

Assessment strategies: shift toward competency-based evaluation

The study highlights a paradigm shift from traditional knowledge-based testing toward holistic, competency-based assessment. Objective Structured Teaching Exercises (OSTE) and reflective portfolios emerged as preferred tools. Reflective portfolios were endorsed as formative, mid-stakes tools that support self-directed learning, metacognition, and professional development. When combined with structured feedback and debriefing, they contribute meaningfully to longitudinal assessment.

Objective Structured Teaching Exercises (OSTEs) are structured, simulated teaching scenarios where students perform brief teaching tasks (e.g., delivering a mini-lecture or providing feedback) to standardized learners under observation [34]. OSTEs allow for objective assessment of observable teaching behaviours, such as clarity, professionalism, and instructional effectiveness, in a standardized, reproducible format with immediate feedback [35].

Reflective portfolios, by contrast, are longitudinal, learner-driven tools. Students collect teaching experiences, personal reflections, feedback, and self-assessments over time. This method fosters deep reflection, self-awareness, and professional identity development, supporting the integration of teaching and ethical competencies. A recent BMC Medical Education study recommends portfolios for their capacity to assess complex, nuanced skills and encourage ongoing reflective practice [36].

However, standardization of HPE assessment remains a global challenge. For instance, while over 90% of U.S. medical schools assess teaching competencies, only 36% of Australian schools report formal HPE evaluation frameworks. Addressing this disparity requires institutional investment, faculty development, and alignment with accreditation standards.

Despite advances, most HPE programs continue to be offered as optional or short courses, lacking sustainability and scalability. Our study is the first from the region to formally propose teaching as a core component of undergraduate medical education establishing the physician as not only a clinician but also an educator committed to lifelong learning [35].

Barriers to effective integration include curriculum saturation, faculty limitations, and resource constraints [13, 28]. Overcoming these challenges demands institutional flexibility and support for context-specific adaptation of HPE content.

Implications for curriculum design

1. Core Competencies:

2. Emphasizing leadership, patient safety, and professionalism equips students for dynamic roles in multidisciplinary healthcare settings.

3. Innovative Teaching Strategies:

4. Preference for small group discussions and case-based learning reflects the global shift toward active learning environments. Incorporation of simulation and skills labs further enhances experiential learning.

5. Pragmatic Assessment:

6. Endorsement of OSTE and reflective portfolios reflects a move toward competency-based evaluation beyond rote knowledge testing.

Implications for lower- and middle-income countries (LMICs)

These findings are especially relevant for LMICs, where formal teaching training in medical education is limited. A validated student-as-teacher curriculum can bridge this gap by fostering academic competencies early, preparing students for peer teaching roles, and promoting culturally relevant professionalism. Additionally, this model can serve as a cost-effective faculty development strategy, reducing dependence on external training programs and contributing to capacity-building within local institutions.

Strengths and limitations

Strengths of this study include its rigorous multi-phase design, high response rate (> 90%), and wide regional representation. The Delphi process ensured consensus through iterative refinement, while anonymity reduced response bias. Alignment with internationally recognized frameworks such as CanMEDS and CBME enhances the study’s relevance and applicability.

Limitations include the exclusion of student perspectives and the lack of feasibility testing at the institutional level. Further research is needed to explore these areas and refine implementation strategies.

Conclusion

This study presents a structured, consensus-driven framework for integrating HPE into undergraduate medical curricula. By aligning core content with evidence-based teaching and assessment methods, it addresses a longstanding gap in medical education. Teaching should no longer remain an implicit expectation but must be explicitly developed as the “eighth star” competency bridging clinical excellence and educational leadership.

Future directions

• Implementation Studies: Pilot implementation of the framework, either vertically or as a standalone subject, to evaluate impact and feasibility.

• Faculty Development: Structured programs to enhance faculty readiness for student-centred education.

• International Validation: Comparative studies to assess the generalizability of this framework across different educational systems.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

HPE

Health Profession Education

SGD

Small-group discussions

LGIS

Large-group interactive sessions

OSTE

Objective Structured Teaching Exercises

WFME

World Federation for Medical Education

CanMEDS

Canadian Medical Education Directives for Specialists

Biographies

Sara Jamil

is the Director Medical Education at Frontier Medical & Dental College and the Executive Director of its affiliated hospital. She also serves as the Head of the Department of Obstetrics and Gynaecology at Shahina Jamil Trust Hospital. With an MHPE from Riphah International University, she has a strong interest in curriculum development, implementation, and assessment, contributing to advancements in medical education.

Rahila Yasmin

is a Professor of Medical Education, Director of the MHPE Program, and Dean of Riphah Academy of Research & Education, Riphah International University, Islamabad, Pakistan. She is a dentist by profession with BDS, DCPS, HPE, MHPE, and PhD Scholar HPE.

Prof. Dr. Shazia Imran

is a Professor of Anatomy at NUST School of Health Sciences, National University of Sciences and Technology, Islamabad. Her expertise lies in curriculum design, innovation, and assessment. She holds an MPhil in Anatomy and Master’s in medical education from Riphah International University.

Author contributions

SJ conceived and designed the study. SJ, RY & SI collected and analysed the data. RY and SI helped preparing the manuscript by providing feedback. All the authors reviewed the manuscript.

Funding

The study received no grant or funding from any source.

Data availability

The data generated and analysed during the study are available on request. The corresponding author Sara Jamil can be contacted for the data. (sara40_abt@hotmail.com)

Declarations

Ethics approval and consent to participate

The study was approved by the Institutional Review Committee at Riphah International University (Riphah/IIMC/IRC/22/2014). Written informed consent was obtained from all the participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.