Factors Affecting the Learning of Medical Ethics and Etiquette from the Perspective of Medical Teachers and Students of Kermanshah Medical School in 2019

1. Background

Professors and students are the two main pillars of universities, and the primary duty of professors is to teach students. The quality of professors’ teaching significantly improves motivation, vitality, and innovation and increases the efficiency of professors and students (1). The teacher or professor who implements the educational program affects students’ learning, mental activity, behavior, personality, and attitudinal changes. Learning should be a priority for politicians and managers. Therefore, the main issue is to know learning, how it happens and improves, and why teaching does not always lead to learning (2).

Technological progress has caused many ethical issues as a result of its complexity. Each new topic of medical ethics is enough to challenge the traditional medical education system in general and other medical science professions in particular. These challenging topics can be felt in the medical ethics curricula and curriculum presentation, and ethical competencies and appropriate ethical decision-making skills should be considered in the curriculum (3). Education is influenced by five factors: teacher, program, equipment, and educational environment. Each of the mentioned factors can affect students’ academic progress and learning differently. Considering the opinions of learners and teachers in the education process for identifying influential factors improves the quality of education (4). Effective Learning requires good teaching in a conducive learning environment and creative and encouraging methods. Direct interaction of students is one of the most critical research sources (5). Many reasons and documents have been presented in articles on medical ethics about the need for medical ethics education. However, there are still many weaknesses and challenges in quantity and quality.

Medical ethics education should not be limited to a few lectures in all practical and theoretical aspects and should be deeply included in the medical education curriculum (6). Many institutions in Europe and the United States offer integrated national programs in medical ethics education. The primary motivation for such programs is to meet the ever-increasing demand for technical aspects of knowledge in bioethics. The student's final goals are human and ethical components of health care. Teaching ethics includes various methods, from conventional lectures to group discussions of case studies and narratives, problem-based learning, and visual and audio films. Sessions should be designed to be as interactive as possible, and maximum student participation should be encouraged (6, 7).

Strengthening ethical skills and increasing ethical knowledge in medicine is an important goal. Thus, many actions have been taken, some of which are the review of medical ethics education programs in content and methodology in general medicine, designing a long-term ethics theme in medical schools, creating education programs for medical ethics in assistantships tailored to the needs of each field, and providing short-term study opportunities for additional training for researchers and faculty members of national seminars and international congresses with 1-2 day training workshops for different groups. Other programs are taking the medical oath at the beginning of the basic medical sciences and the end of the internship, holding a session of human dignity and patient care in the basic medical sciences, and celebrating the white robe at the beginning of the internship. Medical education will strengthen students’ moral sensitivity (8). The discussion of familiarizing students with the basic principles of attending the university, classrooms, and patient beds, and acquiring the personal and social skills encountered in medical ethics, such as the issues of professional dress and behavior, establishing effective communication with patients, ethics in medical research, duties, and responsibilities of doctors. Therefore, reflection on the teaching and learning procedures of the courses that medical students take in learning medical ethics and etiquette is a theoretical and practical necessity.

2. Objectives

This study aimed to determine the factors affecting learning medical ethics and etiquette courses.

3. Methods

This cross-sectional descriptive study was performed on teachers of relevant courses and medical students of Kermanshah Medical School, Iran, who passed at least one of the medical etiquette and ethics courses in 2018-2019. The sample size was calculated based on Cochran’s formula as many as 201 students were selected by convenient sampling. The data collection tool is a researcher-made questionnaire with two sections on students’ demographic characteristics, including age, sex, academic semester, place of residence (dormitory with parents, private home), marital status, and native/non-native (nine questions in teaching methods, four planning questions, five questions role model, three evaluation questions, and one learning space question) with a 5-options Likert scale of Uzbek impact (1) to very high (5). The questionnaire contents are based on the questionnaire of other studies and validated by reviewing articles and related texts and consulting with prominent experts and professors of the university. The reliability was assessed by conducting an experimental questionnaire among several students using Cronbach’s alpha determination formula as much as 0.8. After completing and collecting the data in SPSS-21 software, demographic characteristics and factors affecting the mentioned courses were calculated and included in the analysis. The mean, frequency, and percentages were determined with descriptive statistics. Data that did not conform to the normal distribution were statistically analyzed by comparing two independent groups.

4. Results

The sample size was 201 people with minimum and maximum ages of 17 and 34 years (31.28 ± 2.68 years), of whom 44.3% were male, and 55.7% were female. A total of 54.7% of residents lived in a family home with their parents, 94% lived alone, and 72.8% were indigenous. In order to facilitate the participants’ responses to the instrument items, all the items were standardized to a five-point Likert scale, ranging from score one (low effective) to score five (high effective), because of the importance of the impact, the sum of high and very high-impact responses was considered to favor the agent or method. The factors and their percentages, with the high/very high impact as the most preferred option by students summarized (Table 1).

The questions related to the role of models got a higher score than the rest fields, even teaching methods. These items were also considered effective in a better learning environment by the professors, as well as the most desired option by the students, which had a high impact. Group work in medical etiquette and ethics classes (48.2%), class planning and scheduling (47.4%), detailed design of questions based on the introduced textbook (46.4%), preparing a textbook and lesson plan and presenting it to students at the beginning of the semester (46.2%), questions and answers in class (45%), and holding medical etiquette and ethics classes as a workshop (44%), in professors were aligned with the students.

In contrast, more than half of the students (53%) did not consider medical etiquette lectures as practical as learning, choosing the ineffective option. In addition, 43% consider medical etiquette lectures ineffective in learning better, and their most preferred option is the ineffectiveness of this measure. There is also a difference between the opinions of teachers and students. Students believed that this method was ineffective and most of their choices were ineffective, but professors strongly disagreed and accepted the high effectiveness of this method. According to students, the impact of continuous and non-absent attendance in class and active and dynamic listening on better learning was intermediate with low impact. Active and dynamic listening is effective in better learning and their most desired option is the high impact of this action without absenteeism. A total of 31.9% of students believe that doing research projects in ethics by students is effective in improving their learning, but they prefer the low impact of this method.

Students (54.9%) consider medical ethics and etiquette courses to be effective in improving their relationships with patients, and their preferred option is high impact. Both professors and students believe that teaching and learning medical ethics and etiquette improves students' relationships with patients. The most preferred option was the very high impact (About 20% of students had clinical experience). In a survey, 45.4% of students said that teaching and learning medical ethics and etiquette courses could improve students' professional behavior and speech, and their preferred option was high impact. Medicine is effective in students’ professional behavior and speech, and their most preferred option was high impact.

Only the case of "having pre-class pre-study by topic" differed significantly between the sexes (P < 0.05). There was no significant difference between the two sexes in other factors. There was no significant difference in the questions regarding age, place of residence, and being indigenous or non-indigenous. Regarding the semester, the following items were significantly different between different semesters: holding classes as a workshop, preparing a textbook and lesson plan and presenting it to students at the beginning of the semester, reviewing key points and summarizing in the class, questions and answers in the classroom, physical space, and classroom amenities, and audio-visual facilities. The detailed questions design differed significantly based on the introduced textbook (P < 0.05).

5. Discussion

In this study, the professor’s intimacy with students, scientific mastery, clear expression of professors, acquaintance with leading professors and moral model in university, physical space, classroom amenities, audio-visual facilities, reviewing key points and summaries in the classroom, using animation, educational images and infographics, applications and cyberspace in medical etiquette and ethics classes had a more significant impact on students and professors in learning medical etiquette. There was no alignment between the opinions of students and professors in cases of continuous attendance without absenteeism in the class and active and dynamic listening, having pre-class pre-study based on regular class topics and tests.

Ghamari Zare et al. examined the views of Arak nursing students on the factors affecting the learning of pharmaceutical care in clinical education. Based on the results, strengthening the characteristics of teachers, employing efficient teachers, adapting the environment, paying attention to the characteristics and motivations of students in gaining experiences, understanding the importance and necessity of acquiring knowledge, proper practice of medicine, and providing solutions to increase clinical learning in students can strengthen the learning process of medication care. The teachers’ characteristics and environment adaptation were similar to the present study, but other cases did not match, which could be due to differences between students and the type of course (5).

Seyedmajidi et al. studied factors affecting theoretical courses' learning from the Babol dental students' perspective. Interpersonal relationships, personal factors, and educational facilities were the most influential factors in learning in theoretical courses. The variables of gender, academic years, and educational status do not make a significant difference in students’ perspectives, similar to this study in demographic variables. Regarding influential factors, educational facilities were as effective as the present study (9). Mehralizadeh et al. explored the views of Semnan University of Medical Sciences medical students on the factors affecting anatomy learning. Students believed the use of new teaching methods and various teaching aids, simultaneous teaching of theory and practice of anatomy, expressing the importance of anatomy knowledge in the clinic, along with the good expression of the professor, has the most significant impact on learning anatomy. In the present study, new methods such as animation, teaching aids, applications, and cyberspace, in conjunction with clear and expressive communication by teachers, were found to be effective. In addition, there was no significant difference between the student’s opinions of different levels about the effect of factors such as good teacher expression, use of modeling and educational images, and expression of clinical application of anatomy knowledge in the classroom. Hence, students at different stages had almost the same views on the factors affecting the increase in learning anatomy, which was not consistent with the present study because the results showed that the semester had a significant difference in answers (10).

Mousavi and Javadi identified factors improving students’ learning from the perspective of non-clinical medicine professors of Bandar Abbas Medical School. The teaching method, personality-behavioral dimension, and scientific-literacy dimension were the first to third priorities. Attention to creativity and innovation, determining the content and objectives of the lesson at the beginning of each session, the importance of teaching method and its appropriateness to the lesson content, optimal use of class time based on the content volume, and observing the coherence of lesson concepts. Literacy should guide education based on mastering the concepts of the day. The teacher should have sufficient knowledge about the relevant course and introduce specialized resources to students. Respecting the student incredibly was one of the most influential factors in students' learning in the personality-behavioral dimension (11).

Managheb et al. evaluated the teaching methodology and evaluation of medical ethics courses from the perspective of teachers of medical ethics courses teachers of Shiraz and Jahrom universities. The internship course was the best teaching time from the teachers' perspective. The best place to teach is the classroom and the clinical skills center, and the best teaching methods were lectures and group discussions, respectively. The best way to evaluate the written test and the work report did not agree with the present study, probably because only professors have studied the course of medical ethics (12).

Midgley (13) showed that the most important determining factor in effective teaching is faculty performance and knowledge, consistent with the present study. Akbari et al. compared faculty and students’ views and examined Mashhad dentistry and showed that the opinions of professors were similar to those of students in most cases, which was identical to these results (14). Khaghanizade et al. investigated the challenges of medical ethics education related to professors of the Tehran University of Medical Sciences in qualitative research. The analysis of the interviews with the participants led to the extraction of three themes: the professional ability of medical ethics professors, medical ethics education with active teaching methods, and ethical model. Each topic includes several main and subcategories, each describing a specific aspect of the challenges in teaching medical ethics related to professors. The professional ability of the professors of medical ethics in this study students emphasized the professors’ ability to teach medical ethics with active teaching methods, which was entirely in line with the present study. The students showed this importance by choosing active teaching methods to be very effective. Models had a higher priority in this study than the rest of the fields (15).

5.1. Conclusions

In this study, many factors affecting the learning of medical etiquette courses were similar to other courses. Still, all cases should be considered by professors and students regarding the importance and priority of influential factors. Learning was mainly in line with the factors influencing the learning of these common and parallel courses, which could be used to the fullest extent in promoting the teaching of these courses.