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Development of student’s self reliance and decision making during study in

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The Medical Journal of Tikrit University (1999);5:117-122

Development of student’s self reliance and decision making during

study in Tikrit University College of Medicine.
G. Y. Mustafa–Alsheikh, Abed I.M. Allan, Nabeel D. Sulaiman
Tikrit University College Of Medicine (TUCOM), P. O. Box 45, Tikrit 28001, Iraq.

Abstract
The ability to make decisions and self reliance are essential to the doctor to be able to
perform competently. The competency based problem based educational programme at Tikrit
University College of Medicine (TUCOM) include considerable learning and training
opportunities for students to acquire number of essential competences as early as first year.
The ability to rely on own self and make decisions are among the hidden curricular
competences. This study uses Sack’s Sentence Completion Test (SSCT) to evaluate the two
abilities shown by a cohort of students in TUCOM before start of study and after two and a
half years of study over early the importance of professional skills they need to acquire during
study years. Comparing data taken before and after study, results show a decrease in number
of students with negative personalities who feel completely incompetent in regard to the two
abilities and being hopeless and increase in number of students with positive personality who
feel confident on own ability to overcome obstacles. Difference in regard to both abilities of
self reliance and decision making are statistically significant.
Med. J. Tikrit Univ. (1999);5:117-122
Keywords: Medical Student; Self reliance; Decision Making; Competences; Tikrit Iraq.
(3)
century . In the last ten years, number of
Aim studies appeared to study the philosophy behind
these and other skills and competences and
(4)
The study aims at evaluating students’ trying to prioritize as a separate entity and
self reliance and decision making before and how the doctor among the team is found more
(5)
after spending first two years of study in Tikrit often to make personal crucial decisions .
University College of Medicine (TUCOM) and Moreover, increasing number of regulatory and
eliciting any difference. training institutions are implementing tests for
graduates different from the usual tests of
knowledge and clinical skills like the tests
Introduction conducted by the Medical Board of the State of
Ohio and the Educational Council of Foreign
(6,7)
Medical Graduates in USA . These and other
No doubt, doctors always need to certifying tests are now mandatory for any
possess the skill of decision making in daily graduate from foreign medical school before
work where they are required to solve variable allowed to enter labour market. These tests
medical and health problems. For each problem require acquisition of such competences as self
faced, the doctor has to make a number of reliance and decision making among other
decisions. Decisions may be general like requirements like medical knowledge.
choosing the appropriate procedures or may be Throughout long years of medical study,
specific when choosing from alternative traditional teaching and training lack clear and
diagnostic tests, medicines, and whether to real curricular opportunities for students to
admit patient, refer or send home. Such daily acquire these competences
(4)
apart from
decisions necessarily need self dependence and concealed and unclear opportunities in last
exploring resources to reach the right decision. year/s. In such case, majority of graduates
In the past few decades, these skills have appear to have passed the final year
attracted enormous attention of decision makers examinations without acquiring such abilities. In
(1, 2)
responsible on preparation of doctors which an earlier study in Iraq, evaluating the
were much neglected by researchers until mid- competence of rotating residents in handling fifty

117-122
simulated patient-management clinical
problems, falling under the purview of the major
clinical disciplines, which they come across
during their routine work, the results were
(8)
stunning . A striking number (98%) of over half
of the newly graduated Iraqi residents failed to
reach the minimum pass level (MPL) of
competence taking their overall performance in
the major clinical disciplines. No significant
variation in performance was observed in
relation to the university of graduation in 1981
(Baghdad, Mosul, Basrah and Mustansiriyah).
During the last 30 years, increasing number of
medical schools in different countries started to
drastically reform their education towards
student-centredness and problem solving as in
(9)
McMaster, Canada , Maastricht, The
(10) (11,12)
Netherlands , Harvard, USA , Suez
(13) (14)
Canal, Egypt , Gezira, Sudan to name a
few. The new innovative curriculum provides
ample opportunities devoted for students to
acquire these competences both in learning and
in assessment. The World Health Organization
has formulated the five roles expected from the
doctor to play in the twenty first century namely
care provider, decision maker, communicator,
(15)
community leader and manager . The role of
being a decision-maker can be seen ranked only
second to care provider.
In 1987, a new medical school in Tikrit
th
was decided to be the 8 operating medical
college in Iraq enrolling first batch of students in
September 1989. The local, regional and global
scenes of medical education pushed the
establishment of a totally different innovative
(16)
programme . Among other educational
strategies and characteristics, the new
curriculum offers ample opportunities for
students to acquire abilities of self-dependency
(16, 17)
and decision making . studying Physics, Chemistry and Biology in
(1) The pivotal learning activity is based
around weekly 6 hours of scheduled
and structured small group discussions.
The discussion involves all students in
brain storming process aiming at
acquisition of self dependency and
decision making following critical
analysis towards setting up the week’s
learning objectives, spend time in self
learning and attend different
teaching/learning activities and
concluding at the end of each week.
(2) Student-centred educational strategy
where number of didactic teaching is
kept to a minimum of 2 hours a week.
This creates a learning need among all
students to get trained on the self
learning which depends mainly on self
reliance and personal decisions in
117-122
choosing among the different learning
resources.
(3) Each student is required to write and
discuss a weekly scientific report on the
learning experience during the week.
Designing, choosing and presenting the
content of the personal report requires
innovation, self reliance and decision
making among other abilities. Each
report is evaluated by tutor with
feedback and scoring.
(4) The early exposure of students to field
training (from year one) according to a
plan primary health care sector and later
hospitals provides real opportunities for
students to train on number of abilities
including effective communication, self
confidence and decision making to get
best results from community.
nd th
(5) During four consecutive years (2 to 5 )
small groups of students plan, execute,
write up, present and publish a
community research project. This is a
curricular longitudinal module with a
pass/fail score where each groups are
supervised by faculty from all different
departments. This exercise depends
heavily on team work self reliance and
decision making with high competition
among groups to achieve distinction and
publishing of their work.
(6) The curriculum affords additional
prospects for students to practice
positive attitudes and behaviour which
has close relationship with decision
(18)
making .
While students in other Iraqi medical
colleges spend their first year in college campus
addition to introduction to Anatomy, students in
TUCOM start their first year with a 6-week block
on Introduction to Medical Study. See table 1.
Exposure to communities and patients takes
place as early as first week. During this block,
students acquire knowledge, skills and attitudes
that enable them to effectively attain, during the
coming 6 years, the abilities needed to work as
a generalist junior doctor. These abilities
include: what, why, how and where they ought
to learn to be able to work as a successful,
effective and efficient doctor upon graduation.
They learn how to plan their study, seize all
opportunities to achieve their objectives. They
learn that they should not totally depend on what
is “given” to them but to look for their gaps to fill
from any resource. They learn what is needed to
(16)
become a doctor .
It is not infrequent to recognize in
literature that evaluation of clinical skills,
competences and performance is still a
problematic task where different approaches
(19)
yield different results . In an earlier study
involving 301 newly graduated residents
representing 55% of graduates from four Iraqi
medical schools, competency-based
assessments in defined simulated experiences
were evaluated against their supervisors’
assessment of residents’ daily performance in
hospitals. On the basis of supervisors’
observation of the clinical performance, around
two thirds of residents were considered
competent while less than 2% of residents were
considered competent based on assessment in
(8)
simulated patient management scenarios .
This study aims at assessing the
influence of three years of study in Tikrit
problem based programme on self reliance and
decision making as essential elements of
students’ future clinical competence by using a
different approach and tool.
Material and Methods
As part of enrolment interview that Tikrit
medical college introduced to assess different
skills and attitudes at entry, a sentence
completion test was used. This interview aimed
at determining candidates’ fitness for medical
study and forecasting gaps in individual
competences to provide needed support during
forthcoming study years. The Sack’s test
questionnaire is composed of 60 questions
tending to reflect the kind of person’s different
(21)
aspects of attitudes, affects and concepts . It
is used to test different areas of conflict and
disturbances, interrelationship among attitudes
and personality structure. The set of questions
used in this study comprised of 24 questions
related to individual’s self reliance (self
dependency) and decision making. Each of the
24 questions was coded to belong to either
ability of self reliance/dependency or decision
making. The questionnaire was revised and
translated to Arabic language to assure
specificity of the test by using native language
(20)
. The study population was the students of
the first batch enrolled in September 1989
totaling to 87 in number. The test was
administered on the interview at the enrolment
th
day (4 October 1989) and before start of the
study. The same questionnaire was re-
administered when same batch of students was
th
in their third year of study on 14 March 1992.
The number of students then was only 62 mainly
due to transfer of students to other colleges for
social and financial reasons. Out of the 87
responses obtained in 1989, 25 were excluded
to match those no longer studying in Tikrit. The
responses were interpreted in objective analysis
and independently categorized by three scorers
into three groups: (1) positive response meaning
confident on own ability to overcome obstacles;
each response in this category was allocated 2
(21)
scores ; (2) negative response meaning
feeling completely incompetent in regard to the
ability and being hopeless; each response in this
category was allocated 0 scores; (3) mixed
positive/negative response meaning feeling
confident on own ability but tending to fear
difficulty; each response in this category was
allocated 1 score. The majority of any of the
three categories was taken as the dominant
response for each student. Out of three
independent scorers, only agreement of at least
two was taken into account for each response.
Statistical analysis was done using paired t-test.
Results
The analysis of the total 1488 responses
of the 62 students yielded three categories of
personality as related to the two abilities of self
reliance (SR) and decision making (DM) as
described above. Before starting study (group
1), number of students with SR was 8, without
SR 24, mixed (with conflict on SR) 30; with DM
6, without DM 12 and with conflict on DM 44.
After study (group 2), number of students with
SR was 10, without SR 17, mixed (with conflict
on SR) 35; with DM 15, without DM 8 and with
conflict on DM 39 (table 1). The change in
abilities after study shows decrease in number
of students with negative and increase in
positive in both abilities of SR and DM.
Statistical analysis by using paired t-test shows
significant p-value in regard to change in
number of students for both abilities with shift of
negative to positive personality (table 3).
Discussion
No doubt, the work of the medical doctor
in any work place and in any health facility
demands the acquisition of a number of abilities
to enable the doctor to promote health among
communities, families and individuals through
diagnosing and treating the sick and promoting
the healthy and preventing disease. It is well
known that each step of the work towards
solving the health problems of individuals and
communities needs ability to rely on own self to
(4,5)
make the different appropriate decisions .
Choosing between options like referring a
patient or admitting or treating and sending back
home are vital and serious decisions to start
117-122
with. Similarly vital, choosing the appropriate
option among many options in every piece of
work involves saving lives or not. Accordingly,
the assessment of the effect of teaching,
learning and training on the students, especially
upon graduation, should be an integral part of
the assessment to ensure capability to do the
expected job. The passive teaching, learning
and training offered by the subject based
curriculum in majority of medical colleges offer
diminutive prospects for students to acquire
such abilities. Hence, >90% of residents recently
graduated from four Iraqi medical colleges in
1980-1981, failed to attain the minimal
performance level in managing simulated patient
common cases against >50% found by their
work supervisors to be competent in their
(8)
performance . In Iraq, there is an increasing
degree of complaint and negative feedback on
new graduates from the work field represented
(22)
by ministries of health . However, licensing
and regulatory bodies in developed countries
have started to introduce specific assessments
based on competences as integral part of the
licensing process of foreign medical graduates
(23,24)
. Such development forced and guided
medical schools in different parts of the world to
revise their curricula to enable their graduates to
deal with such competency-based assessments
(6)
. Likewise, medical schools adopting problem
based learning started to ensure provision of
learning and training opportunities to allow
students to practice such competences as early
as first year of study. Several evaluative studies
of graduates of these colleges showed marked
difference as related to such competences when
compared with graduates of subject-based
(9,25,26)
programme . doing by students as pivotal focus of medical
Tikrit University College of Medicine
(TUCOM) has adopted innovative programme
since its foundation in 1989 and it is the only
Iraqi full member of the “Network of community-
oriented educational institutions for health
(27)
sciences” since 1990 . The programme
provides students with more scheduled hours
devoted to active learning and training with
minimal passive teaching when compared with
other Iraqi medical colleges as shown in table 2
(16,17,18,28)
. The use of Sacks sentence
completion test in this study showed
straightforward results. There is a noteworthy
decrease in number of negative personality for
both self-reliance and decision making
competences and increase in number of positive
responses after study in TUCOM for more than
two years (tables 1 and 3). For the difference
between group 1 (before study) and group 2
(after 2 years study) as related to Self Reliance,
the two-tailed P value equals <0.01. By
conventional criteria, this difference is
117-122
considered to be statistically significant. On the
other hand, the difference between group 1
(before study) and group 2 (after 2 years study)
for Decision Making, the two-tailed P value
equals <0.04. Again, by conventional criteria,
this difference is considered to be statistically
significant (table 3).
The nature of the mixed (conflicted)
personality is predicted as a transitional stage to
change where majority of students are still
possessing the positive ability but accompanied
with fear of threats that affect their use of such
abilities. Such finding shows the anxiety and
conflict these students are experiencing as they
represent the first ever Iraqi students studying
medicine in a new way that needs to prove its
success in future. This was a useful result in
identifying students’ needs for academic support
and assurance through more motivation and
active participation.
It seems legitimate and justifiable to
assume that the change in the abilities of self
reliance and decision making among the cohort
of students came about as a result of two solid
years of active learning and training with
objective student participation (table 2).
However, a comparative study with students
from other medical colleges can clarify
difference in abilities that results in the
programmes based on passive teaching where
students are passively dictated vast knowledge
on separate subjects. Such passive educational
teaching has been heavily criticized for many
decades since the well known letter written by
Harvard faculty to the American Medical
(29)
Association in 1849 which clearly appraised
self-reliance, decision making and learning-by-
curriculum. Medical schools trying to squeeze in
the new content by increasing the number of
lectures but the deadening ineffectiveness of
this approach was pointed out in the Harvard
letter: “Lectures do not promote this activity
(learning) especially when there are four, five,
and six of them a day. Learning is a thing no
one can do for another. The weight of education
must fall on the learner; what he does not get
(29)
and make his own …he does not get at all” . It
is amazing to note how “medical” students
studied the profession in old eras when a
prominent Hakim Ibn Radhwan Al Masry (late
tenth century BC) describes the ideal way of
teaching the profession in his book entitled: “The
useful in teaching the profession of medicine”
(30)
. He addresses in page 102 the learner to
own self-reliance and decision making by stating
“Between you and yourself, do not leave behind
anything to the next unless you master it and
view it as logic and if you find yourself
suspicious of it go back to its depth until you
discover its comprehensive nature and you find
no further suspicious issues”. It is obvious that
what we know nowadays as self-learning has its
roots deep in history of teaching of the
profession of healing. It took Harvard Medical
School 140 years to accept the active learning
concept and adopt the “New Pathway” PBL
(11,12)
curriculum . The question is how long it
would take for medical colleges’ communities in
Iraq and the region to get convinced of self
learning and reform their curricula accordingly.
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Table 1: Number of students with negative, positive or mixed (conflicted) personality in regard to self reliance and on
decision making before and after study.
Survey time Self dependence Decision making
Negative Mixed Positive Negative Mixed Positive
Before 24 30 8 12 44 6
After 17 35 10 8 39 15

Table 2: Average curricular hours devoted to different teaching/learning activities in Iraqi medical colleges as of 1989
Teaching/learning activities
Passive Active Mixed Total
Tikrit medical college 3 13 9-12 25-28
Other medical colleges 16 - 12-16 28-32

Table 3 showing paired t-test values for difference between group 1 (before study) and group 2 (after 2 years
study).
Ability Groups Mean SD SEM t-test SE Difference P value
Self Reliance Before 1.26 0.68 0.09 2.6106 - 0.056 <0.01
After 1.11 0.66 0.08 df = 61
Decision Before 1.10 0.53 0.07 2.0843 - 0.101 <0.04
Making After 0.89 0.60 0.08 df = 61

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