Perspectives of faculty, students and patients on clinical skills teaching in undergraduate medical education in Pakistan: a qualitative study

Abstract

Objectives

To explore the challenges and opportunities in clinical skills teaching and learning among faculty, final-year medical students and patients at a private medical university in Pakistan, within the context of a low- and middle-income country (LMIC) medical education system.

Design

An exploratory descriptive qualitative design using inductive thematic analysis utilising in-depth interviews and focus group discussions, framed within a metaphorical lens.

Setting

A single private-sector tertiary care teaching hospital and affiliated undergraduate medical college in an urban setting in Pakistan.

Participants

A total of 48 participants were included in the study: 12 clinical faculty members representing various disciplines and levels of experience, 16 final-year medical students and 10 house officers and 10 patients from adult inpatient wards. Participants were purposively selected to ensure maximum variation in perspectives.

Results

Six key metaphorical themes emerged, each reflecting both the challenges and opportunities within the clinical learning journey: (1) The Safety Harness—simulation as an opportunity for structured, risk-free skill development, yet limited by authenticity; (2) The Underwater Life—the irreplaceable but unpredictable nature of bedside learning in fostering empathy and communication; (3) The Stormy Seas—systemic and cultural barriers such as patient availability, gender constraints and limited faculty resources; (4) The Ship—students navigating self-development amid evolving expectations, digital distractions and shifting motivations; (5) The Engine Room Tools—balancing diverse teaching modalities while seeking optimal time distribution between simulation and bedside learning; and (6) The Guiding Compass—the pivotal role of clinical teachers as mentors and professional exemplars. Triangulated perspectives revealed that while structured simulation and bedside experiences complement one another, significant institutional, ethical and pedagogical challenges persist, many amplified by the realities of resource-limited LMIC settings.

Conclusions

This study underscores the complexities of clinical teaching and learning in an LMIC context, highlighting the need for a balanced, context-sensitive model that integrates simulation with authentic bedside exposure, supported by mentorship and reflective practice. Addressing structural and faculty-related barriers is essential to advancing equitable, patient-centred clinical education in resource-constrained environments.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study explores the perceptions of faculty, students and patients on clinical skills teaching within a low- and middle-income country medical education context, offering a comprehensive, multi-stakeholder perspective and addressing a gap in existing literature that often focuses on single-group or quantitative assessments.

• The use of a qualitative approach enabled deeper thematic insight into stakeholder perceptions around clinical skills teaching and learning.

• Employing qualitative methods addressed a key methodological gap in the field, capturing the depth, context and relational dynamics of clinical learning that structured surveys or quantitative tools often overlook.

• Data collection and transcription by a single researcher ensured procedural consistency and contextual sensitivity, while analysis by two independent investigators minimised bias through consensus-based coding and reflexive discussion.

• The study was conducted at a single private-sector medical college and teaching hospital, which may limit generalisability to other regional contexts, but findings offer context-sensitive guidance for strengthening clinical education in resource-limited environments.

Introduction

Clinical competence, defined as the ability to make accurate medical decisions while prioritising patient care, confidentiality and communication, is a fundamental attribute for physicians worldwide. The acquisition of clinical skills is an essential component of undergraduate medical education and directly influences the ability of future doctors to provide high-quality care.¹ However, concerns regarding the decline in bedside skills and clinical competence among graduates have been increasingly reported, with students demonstrating weaker proficiency in essential skills.^{2 3} These challenges underscore the need to re-evaluate the current methods of clinical skills teaching and learning within medical curricula to ensure that graduates are well-prepared for real-world patient interactions.

Globally, medical education has undergone a paradigm shift from traditional bedside teaching to more structured and simulated learning environments.⁴ Simulation-based education, including standardised patients, mannequins and virtual training, has been increasingly integrated into curricula to provide a controlled, risk-free learning experience.^{5 6} However, while simulation offers advantages such as standardised assessment and procedural skill practice, it may lack the authenticity and unpredictability of real patient encounters, raising concerns regarding its transferability to actual clinical settings.⁷ Bedside teaching, once considered the gold standard for clinical training, has seen a declining emphasis due to time constraints, increased patient loads, faculty shortages and ethical concerns regarding patient consent.^{8 9} These factors further necessitate a well-integrated approach that balances simulation with bedside exposure to ensure the development of both technical proficiency and interpersonal competencies.

In low- and middle-income countries (LMICs), medical education faces additional challenges that impact clinical skills training. Limited patient availability, a high student-to-patient ratio, insufficient faculty development programmes and cultural barriers hinder students’ exposure to patient interactions.^{8 10} Furthermore, the increasing reliance on digital resources and screen-based learning has led to a shift away from hands-on patient engagement, affecting students’ confidence and ability to conduct thorough clinical assessments.¹¹ The COVID-19 pandemic further exacerbated these gaps, as clinical rotations were significantly restricted, depriving students of bedside experience and disrupting their skill acquisition.¹²

Despite these challenges, few studies have comprehensively examined how faculty, students and patients perceive the evolving balance between simulation and bedside teaching within undergraduate clinical education in LMICs. Existing research in Pakistan has largely explored these domains in isolation, focusing either on faculty or student viewpoints, while patient perspectives remain largely absent.¹³,¹⁵ Moreover, most available studies emphasise descriptive accounts of teaching methods rather than the underlying challenges and opportunities shaping effective clinical learning in resource-constrained environments.

This study aimed to bridge these gaps by exploring the experiences and perceptions of clinical faculty, medical students, house officers and patients regarding clinical skills teaching and learning at a private medical college in Pakistan, an illustrative example of an LMIC context where resource limitations, patient diversity and cultural factors uniquely influence bedside and simulation-based learning. By using a qualitative, multi-stakeholder approach, it aims to identify system-level barriers and facilitators in clinical skills education and to inform the design of context-sensitive curricular improvements to enhance clinical skills acquisition.

Methods

This study employed an exploratory qualitative research design to investigate the experiences and perceptions of clinical faculty, final-year medical students, house officers and patients regarding clinical skills teaching and learning. The study was conducted at Jinnah Medical and Dental College (JMDC), Karachi, and its affiliated teaching hospital, the primary training site for undergraduate and house-officer clinical rotations, offering exposure to a diverse patient population. Data were collected for a period of 3 months, January to March 2024, after obtaining ethical approval from the institution.

To recruit participants from each sub-group, purposive sampling was employed to ensure inclusion of individuals who could provide rich, diverse and contextually informed insights into the teaching and learning of clinical skills. This approach prioritised variation in experience and perspective, rather than statistical representativeness, to achieve depth and breadth of understanding. Faculty members were selected based on having at least 5 years of teaching experience in clinical settings. Final-year students and house officers were recruited from the ongoing cohort at JMDC to capture perspectives of those currently undergoing clinical training. Patients were included if they had experienced interactions with medical students during their hospital stay, ensuring firsthand insight into patient encounters in a teaching hospital environment. Individuals not willing to take part in the study were excluded. Participants were invited through departmental announcements and institutional email. All received an information sheet describing the study’s purpose, voluntary participation and confidentiality safeguards. Written informed consent was obtained for participation, audio recording and use of anonymised quotations. Sample size for each subgroup was guided by iterative review of transcripts to assess data saturation, defined as the point at which no new codes or insights emerged.^{16 17} After every two to three interviews, the research team met to review preliminary codes and assess data redundancy. Recruitment continued until two successive interviews yielded no substantially new codes or perspectives, indicating saturation.

Data collection utilised semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs). Semi-structured interview guides were developed after reviewing existing literature and using Wenger’s Situated Learning Theory and Kolb’s Experiential Learning Theory as guiding frameworks. Situated Learning Theory emphasises that knowledge and competence are co-constructed through social participation and mentorship within communities of practice, aligning with the faculty-student-patient interactions explored in this study. Kolb’s Experiential Learning Theory complements this by describing learning as a cyclical process of concrete experience, reflection, conceptualisation and experimentation, mirroring how students acquire and apply clinical skills through both bedside and simulated encounters. These frameworks collectively informed the structure and content of the interview guide and provided a conceptual lens for interpreting findings. Each guide was piloted with one faculty member, one student and one patient before full-scale data collection, ensuring no further modifications were required (the interview guides can be found as online supplemental material 1).

All interviews and discussions were conducted by a single trained qualitative researcher (FAS), a medical educator with formal training in qualitative research and clinical experience in undergraduate medical teaching. The researcher had prior familiarity with the institutional context but no direct evaluative relationship with participants, minimising potential power imbalances. Reflexivity was maintained through ongoing documentation of personal assumptions and reflections in a reflexive log throughout data collection and transcription. A second investigator (MI) independently contributed to data analysis, enhancing interpretive balance and minimising single-researcher bias.

Interviews were conducted in a private designated meeting room, with each discussion lasting 30–45 min. Faculty, students and house officers were interviewed in English, while patient interviews were conducted in Urdu, with subsequent translation and transcription into English for analysis. All sessions were audio-recorded with participant consent to ensure accurate data collection and transcription. To maintain trustworthiness, the interviewer summarised key points at the end of each session, allowing participants to verify the accuracy of their responses.

Data analysis

All data were transcribed verbatim in English by the moderator within 24 hours of each discussion to preserve the integrity of responses, ensure consistency and accuracy and incorporate relevant non-verbal cues noted during the sessions. Non-verbal cues recorded in field notes were used to enrich contextual understanding during coding, particularly to interpret tone, emotional emphasis or hesitation in participant narratives.

Following transcription, the lead researcher reviewed the data with a co-investigator to discuss emerging interpretations and potential biases. Data analysis was conducted independently by two researchers using inductive thematic analysis. Both investigators manually coded and categorised responses, followed by consensus-driven discussions to refine and merge codes into broader themes. During analysis, metaphors and symbolic expressions used by participants were examined to capture the deeper meanings underlying their descriptions of teaching and learning. These served as interpretive anchors for developing higher-order themes that reflected shared experiences across participant groups. This metaphor-based interpretive step followed established qualitative traditions where metaphor is used to reveal conceptual linkages between lived experience and abstract understanding of professional identity and learning.¹⁸,²⁰ Reflexive journals were reviewed alongside transcripts to document analytical decisions and evolving interpretations. During consensus meetings, entries were used to identify and discuss potential researcher biases, ensuring that final themes were grounded in participant data rather than researcher assumptions. There were no pre-determined data codes or categories, as all themes emerged from the data in an inductive way.

Metaphors were used as integrative analytic tools. Each metaphor condensed codes from diverse participants into a shared conceptual frame. This approach allowed us to triangulate across faculty, student and patient perspectives, while also connecting descriptive data to interpretive insights relevant to the research gap.

Triangulation of findings

Triangulation was applied across participant groups and data collection methods to enhance the validity and trustworthiness of findings. Responses from faculty, students, house officers and patients were compared with identify convergence and divergence. To further establish rigour and trustworthiness, Guba’s four criteria were applied, including credibility, achieved through pilot testing and data triangulation; transferability, ensured by providing rich descriptions of the study setting and context; dependability, established through systematic documentation of coding and analysis procedures; and confirmability, strengthened by independent coding, reflexive journaling and consensus-driven theme refinement.²¹

Patient and public involvement statement

Patients or the public were not involved in the design, or conduct, or reporting or dissemination plans of our research.

Results

A total of 48 participants were included, comprising 12 clinical faculty members, 16 students, 10 house officers and 10 patients. Discussions with faculty and patients were conducted as IDIs, while students were engaged in three FGDs and house officers participated in a single FGD. Each FGD comprised 5 to 6 participants per group. Faculty members had teaching experience ranging from 5 to 40 years and represented a variety of clinical disciplines, including medicine (n=3), paediatrics (n=3), obstetrics and gynaecology (n=3), surgery (n=2) and urology (n=1). The patient group included individuals between the ages of 18 and 62 years, with a median age of 35.0 years (23.8–49.3 years). The student cohort consisted of 16 medical students, with the majority being female (n=10). The house officer group comprised 10 recently graduated doctors undergoing internship training, who participated in two FGDs, with an equal gender distribution (figure 1).

Figure 1. Gender distribution across participant groups (n=48).

A central metaphor emerged from the data, depicting clinical skills education as a ship’s journey, where the student is the ship, navigating through stormy seas representing the challenges in clinical teaching and learning. Six overarching themes were identified, reflecting both the challenges and opportunities inherent in clinical skills teaching across simulation and bedside contexts. Each theme represents a dimension of the educational journey: balancing structure and spontaneity, safety and authenticity, mentorship and autonomy (table 1).

Table 1. The ship analogy in clinical skills education.

Metaphor (analogy)	Meaning
The safety harness	Stands for simulation-based learning, which offers a safe, controlled environment for practice, akin to life-saving gear on a ship.
The underwater life	Symbolises the dynamic, ever-changing and unpredictable environment involving patients and bedside teaching and learning.
The stormy seas	Depict the challenges and barriers in clinical teaching and learning.
The ship	Represents the student who has to acquire the qualities and skills required to become a good medical graduate.
The engine room tools	Represents the diverse teaching and learning formats, each contributing uniquely to the learning experiences.
The guiding compass	Symbolises the faculty, who provide direction and mentorship, guiding students through their clinical education.

Theme 1: the safety harness (simulation-based learning as an opportunity for structured, risk-free skill development)

Simulation-based learning serves as a safety harness in clinical education, providing a structured environment where students can develop and refine procedural and diagnostic skills before transitioning to real patient interactions. In an LMIC context, constrained access to high-fidelity equipment, limited lab scheduling and consent-related restrictions on novice bedside participation make simulation especially valuable early on; yet these same constraints can inadvertently prolong reliance on lab-based practice and delay authentic patient contact. Faculty and students recognised its role as a preparatory tool while acknowledging its inability to fully replace real-world experiences. This dual perception positions simulation as both a vital opportunity for structured skill acquisition and a challenge when over-reliance diminishes exposure to the complex realities of bedside care.

Faculty perspectives

Faculty unanimously agreed that simulation-based learning is an essential precursor to real patient encounters. By minimising patient harm and providing opportunities for repeated practice, simulation fosters confidence, self-directed learning and technical competence.

If we have a good skills lab with high-fidelity mannequins, the students can practice as many times as they want… there is no risk with errors and no resistance from the patient.

Additionally, faculty emphasised that procedural skills should follow a progressive trajectory, from simulation to supervised real-world practice.

When you want to develop procedural skills in students—for example, passing a cannula—they should practice in the skills lab first. Once they have mastered it, they can then try it on the patient under supervision.

Beyond procedural training, faculty highlighted the value of standardised patients in teaching diagnostic reasoning and communication, providing a uniform and structured assessment framework.

Standardized patients make it easier to assess everyone equally since each student faces the same situation.

Faculty noted that standardised formats help equalise opportunities when clinical exposure varies across rotations and sites—an inequity more pronounced in resource-limited environments. They also acknowledged certain limitations, particularly in preparing students for the interpersonal, emotional and unpredictable aspects of patient interactions.

Students won’t know how to behave in front of a real patient. Watching videos or practicing on mannequins won’t teach them how to touch a patient as a doctor or how to communicate professionally.

Student perspectives

Students and house officers also expressed strong support for simulation-based education, recognising it as a foundational training that enhances confidence, competence and patient safety. The consensus was that simulation provides a necessary foundation, particularly for procedural training.

You learn a lot of things in the skills lab that one cannot learn directly in the ward.

Students also acknowledged certain limitations, echoing faculty concerns that simulation cannot fully replace real patient interactions. A recurring point was that while mannequins provide structured learning, they lack realism, particularly in terms of patient responses, emotions and variability in clinical presentations.

People take it for granted because they know it is a mannequin. There won’t be any facial grimaces or pain. There won’t be any reaction.

Students also expressed concerns that simulation-based training can become redundant once a certain level of proficiency is reached, making real patient encounters the only way to further refine skills. Some students linked this redundancy to bottlenecks typical of resource-constrained programmes (eg, competition for lab time/equipment and variable bedside access), reinforcing simulation’s role as a necessary but insufficient precursor to supervised patient care.

It is not that performing on a mannequin is bad—it has its benefits—but after a certain point, performing on a mannequin becomes redundant. Performing on a patient then has benefits.

Collectively, these reflections underscore simulation as a stepping-stone rather than a substitute to build foundational competence and patient safety, yet in resource-limited LMIC settings, it remains a continuing challenge to ensure authenticity, sustained engagement and a timely, seamless transition to bedside learning.

Theme 2: the underwater life (dynamic and unpredictable bedside teaching)

Bedside teaching, the ‘underwater life’ beneath the structured surface of medical education, immerses learners in uncertainty, human emotion and clinical variability. In LMIC contexts, high patient volumes, gender norms and hierarchical workflows intensify ethical and logistical trade-offs around privacy, consent and time at the bedside. Across participants, bedside learning was viewed as irreplaceable for developing empathy and clinical reasoning, yet its enactment was constrained by these structural realities, underscoring the need for protected, supervised and dignified patient encounters.

Faculty perspectives

Faculty unanimously upheld the pedagogical centrality of bedside teaching, describing it as the ‘true essence’ of clinical education, where abstract knowledge is transformed into real-life decision-making. This application of theory to practice was seen as the turning point in a student’s evolution, marking the shift from passive learner to active clinician.

How to approach patients, how to demonstrate empathy—that cannot be learned on a mannequin. That the students learn on real patients only.

Faculty remarked that patient interactions demand students respond to unpredictable and often emotionally charged situations, which prepares them to navigate the complexities of actual clinical environments. Notably, they underscored the importance of experiential empathy:

Making them feel the holes by stepping in someone’s shoes is what we do. Only exposure to real patients can instill empathy in them.

Faculty noted that large group sizes relative to patient availability, common in resource-limited settings, heighten dignity concerns and constrain the depth of bedside encounters, particularly in paediatrics and obstetrics/gynaecology.

If you are a patient and you have 20 people standing around you, you will feel embarrassed. So, the patient should be given his due regard.

Student perspectives

Students echoed faculty in viewing bedside learning as central to their transformation from students to doctors. Several students described bedside teaching as a confidence-building experience, often recalling personal stories that marked key turning points in their clinical training.

I remember the first time I approached the patient; my hands were sweaty… and the patient told me I was checking at the wrong place! I was so embarrassed.

Others highlighted how exposure to follow-up care and patient recovery reinforced their learning and gave them a sense of purpose. Students recognised that textbooks and mannequins cannot replicate human variability in disease presentation or emotional response.

Not every patient responds in the same way… At times it is different from what is written in the books.

Despite its benefits, students also acknowledged that initial encounters with patients were emotionally charged, often marked by fear and self-doubt. They also expressed awareness of the ethical boundaries of learning in clinical spaces, acknowledging that patients are often in pain or emotionally unprepared to serve as teaching cases.

When we are doing it (physical examinations) on patients, they are sick, hesitant. They are not giving you consent.

Patient perspectives

Patients generally had positive attitudes towards bedside teaching, valuing their interactions with students and appreciating the benefits of receiving care in a teaching hospital. Several patients described student interactions as therapeutic.

Seeing students around distracts us from our illnesses. Otherwise, we will be constantly thinking about our sickness and will get depressed.

Patients broadly accepted and supported student involvement in their care, with most expressing no objection to being examined or questioned by students. Many patients expressed a sense of moral responsibility and pride in contributing to medical education. Their comments reflected a deep respect for the profession and a desire to contribute to future healthcare quality, a sentiment underscoring a social contract in teaching hospitals, where patients act not just as recipients of care, but as educational partners in training the next generation of doctors.

If we do not cooperate with our future generations, how will they take positions in future?

Theme 3: the stormy seas (challenges in clinical education and training)

This theme reflects the turbulent challenges faced by faculty and students in navigating clinical education. These ‘stormy seas’ highlight how multiple system-level, interpersonal and contextual factors intersect to impede the development of meaningful, patient-centred learning.

Faculty perspectives

Faculty conveyed being caught in a complex interplay of structural, student-related and patient-related challenges that compromise the quality of bedside teaching. One concern was the limited volume and diversity of cases, which restricts opportunities for hands-on training. Without consistent exposure to a broad case mix, students risk emerging with fragmented clinical understanding. This was compounded by patient-related constraints where gender dynamics and consent-related hesitations significantly restrict student involvement. Faculty voiced frustration at situations where cultural norms, patient discomfort or high-paying private patients led to refusals that disrupted teaching.

Faculty also highlighted a cultural shift in learning priorities from deep, integrative understanding to exam-focused, strategic studying. The pursuit of high grades and check-box competencies often results in students bypassing less assessable but vital aspects of clinical learning.

They (students) study for exams only, not for gaining knowledge… But this creates an issue later in patient interaction.

Resource-related constraints further exacerbated challenges. Time-strapped faculty, burdened by administrative responsibilities, found it increasingly difficult to supervise large groups of students meaningfully.

Student perspectives

Students raised several concerns framed from their vantage point: as recipients of a fragmented clinical experience marked by limited access, logistical hurdles and missed opportunities for growth. One prominent frustration was with patient cooperation.

When you take an elaborate history, the patients get annoyed because he/she has responded to so many other students and doctors.

Another recurring idea was inconsistent patient volume, with students feeling that low patient flow during rotations significantly hampered clinical exposure. Communication barriers due to linguistic mismatches were also identified as structural limitations. Finally, the legacy of the COVID-19 pandemic loomed large in experiences of many students, particularly those from the ‘COVID batch’. Having missed out on early exposure to patients, students felt underprepared and disconnected from core clinical competencies that should have been nurtured through regular bedside engagement.

Theme 4: the ship (medical students navigating self-development amid evolving expectations)

Just as a ship needs structure and endurance to withstand the seas, students are expected to build technical proficiency, emotional resilience and humanistic competence. Among participants, there was recognition that this formation is neither linear nor uniform, marked instead by tensions between generational values, educational resources, emotional development and patient expectations. In LMIC contexts, these tensions are negotiated amid high patient volumes, variable supervision and uneven access to learning resources across rotations and sites, shaping how students pace their growth from novice to independent practitioner.

Faculty perspectives

Faculty reflections were a mix of concern, nostalgia and cautious optimism. A pervasive sentiment was that while today’s students are intellectually well-equipped, they often lack a depth of emotional connection that characterised earlier generations.

The kind of bond we used to have with our patients lacks in this generation.

Many pointed to a generational shift in attitudes, noting a checklist mentality that can be reinforced by crowded wards, brief patient encounters and task-oriented rounds typical of resource-limited teaching hospitals.

They have to be in the wards sometimes unsupervised, with the patients so that they can understand the dynamics of whatever is happening with the patient, physically, emotionally, and financially.

Faculty linked limited supervision to staffing constraints and service demands, where competing clinical workloads can compress teaching time and reduce opportunities for guided reflection.

Student perspectives

Student reflections revealed self-awareness and complexity, acknowledging internal and external forces shaping their experiences. A recurring theme was of digital distractions. Students noted how a multitasking culture has fragmented attention spans and pulled focus away from the patient-centred ethos of medicine.

I think [our teachers] were better because they did not have as much of distractions as we do right now.

Additionally, students acknowledged growing financial pressures—tuition costs, family responsibilities and competitive postgraduate pathways—heightening the pull toward income security.

We are distracted. And are more focused on earning money.

Yet, they were not devoid of insight into the advantages of their era. Many celebrated the accessibility of information, reflecting how technological progress has enabled faster, broader learning.

We have internet. If they wanted to find something, it would take them an hour, and we can do it in no time.

Regarding clinical competence, some expressed pride in their resource-based capabilities, while others offered a more humble and introspective view, admiring the passion and resilience of their mentors and doubting their own preparedness. Several students felt that crowded wards, limited privacy and language/cultural differences with patients made emotionally attuned communication harder to practise without dedicated supervision time.

Patient perspectives

Patients offered a compassionate but discerning lens on the competence and character of students. For most, knowledge and politeness were valued above all. Patients spoke warmly of students who showed concern and made them feel heard.

The way they talk, their behaviour. If their attitude is good, then half the illness goes away.

They valued availability and time, often scarce in high-throughput public-facing services, and saw unhurried, respectful encounters as markers of genuine care.

Because a patient is a human, that’s why he should be treated well.

Their emphasis on courtesy and presence reflected a setting where brief encounters and shared spaces are common; small relational gestures can therefore carry outsized weight in perceived quality of care.

Theme 5: the engine room tools (balancing diverse teaching modalities for optimal learning)

This theme centres around the teaching modalities and structural scaffolding that drive clinical education, including simulation-based training, bedside teaching, outpatient exposure, small group tutorials, clinical case discussions and grand rounds. Access to these modalities is uneven across rotations and sites, shaped by faculty workload, patient flow, space limitations and variable availability of simulation equipment and standardised patients.

Faculty perspectives

Faculty described a deliberate and multi-modal approach to clinical skills education, noting that students are engaged across a range of pedagogical formats that span both controlled simulations and authentic clinical encounters. This layered structure is intended to guide students along a scaffolded learning path, beginning with foundational technical competence in the skills lab and progressing toward more complex patient care in real-world settings. Faculty noted that while the scaffolded pathway is ideal in principle, feasibility depends on clinic volume and staffing; on busy services, teaching time and supervised bedside practice can be compressed.

They have their classes, they have their tutorials, they have their CBLs. We have skills lab and then dedicated time for them to spend in the wards and OPDs.

This comprehensive structure reflects an understanding of experiential learning theory, where skill development requires repetition, observation, reflection and application. However, while faculty generally endorsed this multimodal approach, they also revealed personal preferences and pedagogical leanings, particularly in favour of bedside teaching.

Whenever they are with me, I want them to spend time with the patients at the bedside.

These preferences reflect deeper beliefs about the kind of doctor one becomes through prolonged patient interaction—someone attuned not just to clinical signs but also to the emotional and social dimensions of care. Bedside teaching was seen as the ultimate integrative format, bringing together knowledge, skill, communication, professionalism and ethical sensitivity in one immersive context.

I would recommend two thirds of the time by the bedside and one third in the skills lab…Gradually the students should be weaned off from skills lab.

Theme 6: the guiding compass (strengthening faculty mentorship and direction)

Clinical teachers function as guiding compasses, subtly yet powerfully shaping the professional development of medical students through everyday interactions, behaviours and clinical decisions. Beyond structured instruction, it is the modelling of attitudes, ethics, communication and empathy that leaves a lasting imprint on students.

Student perspectives

Students widely acknowledged that their greatest lessons in empathy, professionalism and communication were not taught but observed. Clinical teachers, by virtue of their experience and conduct, become unspoken mentors, modelling how a good physician should behave in the face of clinical complexity and emotional tension. The affective and ethical dimensions of clinical practice are thus transmitted through presence and example, not just through explanation.

Students consistently emphasised that the core attributes of a compassionate physician—empathy, kindness, respect—are learnt by mirroring what they see their seniors doing.

We learn how we should talk to the patient. We have to be kind and polite… They (our teachers) teach us empathy and professionalism.

Importantly, students also recognised that clinical reasoning and judgement, the subtleties of prioritising patient concerns, managing uncertainty and personalising care, are cultivated through close observation of seasoned physicians, revealing an appreciation for experiential intelligence, affirming the role of faculty as living repositories of clinical wisdom. Through these encounters, students are exposed to ways of thinking that go beyond algorithms and flowcharts—ways that are nuanced, patient-centred and grounded in reality.

There are a lot of things which are not present in the books but our consultants know from experience… when they are teaching us at the bedside, we get to understand and see how they think.

Discussion

This study integrated faculty, student and patient perspectives on undergraduate clinical skills education in Pakistan, an LMIC context where resource constraints, patient flow and cultural norms shape learning opportunities. Using a metaphor-driven thematic analysis, we found that simulation provides a structured, risk-free foundation, whereas authentic bedside encounters are indispensable for cultivating communication, empathy and culturally sensitive practice. Clinical teachers emerged as pivotal in modelling professionalism and guiding learners through the emotional and cognitive complexities of patient care.

Faculty emphasised the pedagogical value of multiple formats, skills labs, bedside learning, tutorials and case discussions, with departmental variation in preferences and implementation. Students echoed this need for hybrid exposure but stressed that learning from real patients was more confidence-building and memorable. Patients, meanwhile, welcomed student involvement, citing improved attention and communication as benefits, although cultural and gender-specific limitations persist. These insights align with existing literature that supports blended educational models while reaffirming the irreplaceable value of real-patient interaction in cultivating clinical reasoning and empathy.^{22 23}

Taken together, the six metaphors illuminate three cross-cutting tensions that structure the learning ecosystem in resource-limited settings: safety versus authenticity (simulation builds confidence yet cannot reproduce interpersonal nuance), standardisation/equity versus variability (structured formats help equalise exposure where bedside opportunities are uneven across sites and specialties) and mentorship versus service pressure (role-modelling is crucial but often compressed by clinical workload). Viewing the findings through these tensions clarifies where context-sensitive improvement is most actionable.

At the systems level, participants highlighted inconsistent patient availability, faculty shortages and time pressure, cultural and gender-related consent constraints and student distraction linked to unfocused digital use. Simulation capacity was limited by access to higher-fidelity equipment and scheduling bottlenecks. These patterns, commonly reported in LMIC teaching hospitals, support pragmatic, resource-sensitive reforms rather than wholesale adoption of high-resource models.²⁴,²⁶

Implications for practice and policy

Our findings point to a pragmatic LMIC-sensitive model that links structured preparation to authentic, supervised practice. Medical schools and curriculum committees can strengthen training by adopting competency-based progression with clear milestones or entrustable professional activities (EPAs) so that simulation becomes a deliberate on-ramp to bedside care rather than an endpoint.^{27 28} Simulation should be required for core procedures, scaled to context (low/mid-fidelity locally with shared access to higher-fidelity hubs), and integrated with assessment and debriefing in line with published simulation standards.²⁹ At the systems level, collaboration between hospitals and universities is needed to safeguard real-patient learning through agreements that schedule small-group bedside encounters, set reasonable learner–patient ratios and safeguard teaching time, consistent with WFME expectations for clinical training resources.³⁰ Blended learning approaches, combining case discussions, short tutorials and offline-ready resources, can also help maintain instructional continuity when patient exposure fluctuates, while preserving essential bedside time; evidence supports the effectiveness of blended approaches in health-professions education.³¹

To sustain quality, faculty development efforts should focus on concise, recurring training in bedside teaching, feedback and assessment aligned with EPAs, coupled with institutional recognition of teaching within workload and promotion policies. Patient partnership can also be formalised through advisory participation in curriculum and assessment design, co-creation of culturally relevant cases and standardised-patient scripts and structured opportunities to provide feedback on learner interactions, implemented with safeguards for consent, privacy and fair compensation.

Finally, both faculty and students can engage in brief, recurring reflective practice and resilience-building sessions alongside clinical rotations to strengthen emotional regulation, empathy and communication in complex LMIC settings; meta-analytic evidence indicates that such interventions improve resilience and reduce perceived stress among health-professional learners.³² Together, these steps translate the six metaphors into actionable reforms: a staged pathway from simulation to supervised bedside care, strengthened mentorship and feasible structural supports that equalise access, preserve dignity and cultivate empathic, competent clinicians.

Strengths and limitations

A key strength of this study lies in its inclusion of triangulated stakeholder perspectives: faculty, students and patients—offering a rich understanding of clinical skills education. The metaphor-driven thematic framework enabled a deeper exploration of not just practices but the underlying emotions, tensions and perceptions shaping clinical learning environments. By employing metaphor-driven analysis, we were able to integrate diverse viewpoints into cohesive images that highlighted both challenges and opportunities in balancing simulation and bedside teaching. This integrative function allowed the metaphors to serve not only as descriptive devices but also as vehicles for drawing implications for practice and policy, particularly within the LMIC context. The metaphor-driven approach represents a methodological strength of the study, as it facilitated the synthesis of complex, multisource qualitative data into an interpretable and transferable framework for educational reform. The study also benefitted from methodological rigour through verbatim transcription, reflective logs to mitigate bias and independent coding with consensus-building among researchers. However, certain limitations must be acknowledged. The study was conducted at a single private medical college and affiliated teaching hospital, limiting the transferability of findings to other institutional or regional contexts, including public-sector settings. Additionally, reliance on a single moderator may have introduced facilitator-related bias, despite efforts to standardise data collection. Finally, while the study generated valuable insights, it was not designed to assess long-term outcomes of specific curricular models, leaving room for future longitudinal research.

Conclusion

This study offers a comprehensive and contextually grounded understanding of clinical skills education by exploring the experiences and expectations of faculty, students and patients, highlighting the need for a balanced, multimodal clinical teaching model that integrates simulation with authentic bedside learning, underpinned by strong mentorship and institutional support. While simulation provides a risk-free foundation for procedural competence, bedside teaching remains indispensable for cultivating empathy, communication and professional identity. Addressing systemic challenges requires deliberate policy reform and curricular innovation. By centring the lived experiences of all stakeholders, this study informs a more patient-centred, context-sensitive and pedagogically sound approach to shaping tomorrow’s clinicians.

Data availability statement

Data are available upon reasonable request.