Development Strategies in Medical Education

Introduction
One of the key factors in educational development is the educational environment [1]. Today, clinical education in medical education has received special attention due to providing learning opportunities for students [3]. A constructive educational environment is a necessary prerequisite to encourage and stimulate learning in learners [4]. Attendance in outpatient clinics is an important part of clinical education since it provides students with the possibility of learning about a wide range of diseases, community health, and various situations [5]. The main goals of education in the outpatient clinic are transfer of clinical knowledge, acquisition of history-taking skills and clinical examination, improvement of communication skills, formation of clinical reasoning, acquisition of patient management and treatment skills, learning medical ethics, and formation of professional behaviors [11]. The conditions required for clinical education include: preparation of university professors, preparation of appropriate physical conditions and location, preparation of required equipment, scheduling, determining the number of patients for visit and examination, access to scientific resources, evidence-based citation, registration and documentation, professional ethics, and evaluation [12]. Acquiring basic clinical skills and, in other words, becoming a professional in medicine depends on the quality and quantity of training in clinical settings [13]. Due to the importance of clinical education and its emphasis in the country's medical education system, as well as the role of a proper educational environment in the development of learning, this study aims to evaluate the educational environments in the clinics of hospitals affiliated to Jahrom University of Medical Sciences (JUMS) from the point of view of medical students.

Methods
This is a descriptive cross-sectional study with the participation of 176 medical students (externs and interns) and residents. The data collection tool was the Ambulatory Care Learning Education Environment Measure (ACLEEM), which includes two parts. The first part surveys demographic information such as age, sex, marital status, place of residence, rank. The second part is the main section with 50 items rated on a five-point scale. Data collection was done by a medical student in the hospitals of Jahrom county (Peymanieh, Motahari, and Seyed al-Shohada).

Results
The mean overall ACLEEM score for the educational environment of the clinic of hospitals was 2.23±0.50, which was a moderate level. In the domains of Clinical teachers, clinical activities & patient care, protected time for non-clinical activities, infrastructure, clinical skills, and assessment & feedback, the scores were at a moderate level, while in the domains of “Information. communication & technology”, and “Clinical supervision”, the scores were lower than average level. Among the domains, clinical supervision had the lowest score, while infrastructure had the highest score. The mean scores of ACLEEM were not significantly different in terms of students’ demographic characteristics.

Conclusion
Today, learning in clinical settings is an important part of medical education. In this study, according to the students, the educational environments in the clinics of hospitals affiliated to JUMS were at a moderate level. The results of a study by Ahmadi and Mohammadzadeh, also showed moderate satisfaction of medical students with the educational environment of the clinic of Taleghani Hospital [23]. In another study, it was observed that the professors' perception of the clinical education status and its conditions in the clinic of a hospital was at a moderate level [24]. In another study, it was observed that the condition of the educational environment in the outpatient clinic was at a semi favorable condition [19]. There are many weaknesses and shortcomings in the educational environment of clinics in study hospitals in various areas, according to medical students in this study, which should be taken into account to solve and improve them to achieve higher quality. A constructive and quality learning environment can increase the motivation of students to learn clinical skills.

Ethical Considerations
Compliance with ethical guidelines
This study has ethical approval from Jahrom University of Medical Sciences (Code: IR.JUMS.REC.1402.068).

Funding
This study was funded by Jahrom University of Medical Sciences.

Authors' contributions
Writing proposal: Fatemeh Eftekharian and Amir Mohammad Mehrpour; data collection: Amir Mohammad Mehrpour; data analysis: Navid Kalani; Initial draft preparation, editing & review: All authors.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the Clinical Research Development Unit of Peymaniyeh Hospital in Jahrom county for their cooperation.


References

1. Fitzpatrick J, Sanders JR, Worthen BR, Wingate LA. Program evaluation: Alternative approaches and practical guidelines. Boston: Pearson; 2012.[Link]
2. Parvizi MM, Amini M, Dehghani MR, Jafari P, Parvizi Z. Psychometric properties of the Persian version of the Ambulatory Care Learning Educational Environment Measure (ACLEEM) questionnaire, Shiraz, Iran. Adv Med Educ Pract. 2016; 7:559-66. [DOI:10.2147/AMEP.S112861] [PMID] 
3. Avizhgan M, Farzanfar E, Najafi M, Shams B, Ashoorion V. Ambulatory education quality in Al-Zahra Hospital Clinics in Isfahan, view of clerkships students and interns. Iran J Med Educ. 2011; 10(5):896- 905. [Link]
4. Williams KC, Williams C. Five Key ingredients for improving student motivation. Res High Educ J. 2011; 12:1-23. [Link]
5. Ebrahimzadeh A, Ramezanzdeh k. [Student-centered ambulatory education based on SNAPPS Model (Persian)]. Res Med Educ. 2016; 8(3):17-23. [DOI:10.18869/acadpub.rme.8.3.17]
6. Dent JA. AMEE Guide No 26: Clinical teaching in ambulatory care settings: Making the most of learning opportunities with outpatients. Med Teach. 2005; 27(4):302-15. [DOI:10.1080/01421590500150999] [PMID]
7. Dent JA, Harden RM, Hunt D. A practical guide for medical teachers. Amsterdam: Elsevier; 2021. [Link]
8. Mortazavi S, Razmara A. [Medical student satisfaction in different educational locations (Persian)]. Iran J Med Educ. 2001; 1(3):51-4. [Link]
9. Sparke C, Cantillon P, Metcalf J, Spencer J. Teaching in an ambulatory care setting. BMJ. 2008; 337:a1156. [DOI:10.1136/bmj.a1156] [PMID]
10. Krackov SK, Packman CH, Regana Smith MG, Birskovich L, Seward SJ, Baker SD. Perspectives on ambulatory programs: Barriers and implementation strategies. Teach Learn Med Int J. 1993; 5(4):243-50. [DOI:10.1080/10401339309539631]
11. Ministry of Health and Medical Education. [Medical education standards (Persian)]. Tehran: Ministry of Health and Medical Education; 2016.
12. Pour Aghaee B. [Medical education standards in outpatient clinic (Persian)]. Alborz: Alborz University of Medical Sciences; 2016.
13. Mogharab M, Khazaei T, Amuzeshi Z, Soruri M, Sharifzadeh GR. [Assessing clinical training fields from the perspective of nursing students and instructors in 2010-2011 (Persian)]. Mod Care J. 2011; 8(2):94-9. [Link]
14. Zamani H. [Evaluation of the satisfaction degree amount trainees and Interns with respect to training process in internal and infant department of Arak Medical Sciences University (Persian)] [MD thesis]. Arak: Arak Medical Sciences University; 2008.
15. Khoshgoftar Z, Ahmady S. Comparative study of the performance appraisal systems for academic members’ performance appraisal systems in the various universities in around the world according to the diagnostic model: A qualitative research. Strides Dev Med Educ. 2014; 11(1):75-89. [Link]
16. Riquelme A, Padilla O, Herrera C, Olivos T, Román JA, Sarfatis A, et al. Development of ACLEEM questionnaire, an instrument measuring residents’ educational environment in postgraduate ambulatory setting. Med Teach. 2012; 35(1):e861-6. [DOI:10.3109/0142159X.2012.714882] [PMID]

17. Naghizadeh Moogari Z, Kuhpayezadeh J, Soltani Arabshahi SK. [Investigation of the reliability and validity of the ACLEEM Questionnaire in the evaluation of educational learning environment in ambulatory care teaching hospitals affiliated to Tehran University of Medical Sciences (Persian)] [ Tehran: Tehran University of Medical Sciences; 2013.
18. Salajegheh M, Bahmanbijari B, Shokouhi M, Safipour Afshar A, Beigzadeh A. [Educational environment assessment at outpatient clinics in teaching hospitals of Kerman University of Medical Sciences, Iran, from resident’s perspective based on the ACLEEM Questionnaire (Persian)]. Strides in Dev Med Educ. 2015; 12(1):119-30. [Link]
19. Naghizadeh Z, Kuhpayezadeh J, Soltani Arabshahi SK, Bigdeli Sh, Javid Gh, Tavousi M, et al. [Assessment of educational environment at outpatient clinics in teaching hospitals: Residents’ perspective based on the ACLEEM (Persian)]. Payesh. 2014; 13(5):551-9. [Link]
20. Goldie J. AMEE Education Guide no. 29: Evaluating educational programmes. Med Teach. 2006; 28(3):210-24. [DOI:10.1080/01421590500271282] [PMID]
21. Mousavinia SM. [The correct way to study and learn (Persian)]. Tehran: Daneshyaran-e- Iran; 2022. [Link]
22. Dehghani Poudeh M, Shams B, Ashourioun V, Esmaeilee A, Asilian A, Nasri P, et al. [Internal assessment of Isfahan general medicine curriculum based on basic standards of Ministry of Health and Medical Education: A model for evaluation and analysis of results (Persian)]. Iran J Med Educ. 2011; 10(5):552-65. [Link]
23. Ahmady S, Mohammadzadeh F. [Evaluation of outpatient care educational environment in Ayatollah Taleghani Hospital of Shahid Beheshti University of Medical Sciences from the perspective of medical students in winter 1398 (Persian)]. Iran J Med Educ. 2020; 20:425-8. [Link]
24. Rahmani A, Faraji M, Ahmadi M. [Evaluation quality of ambulatory medical education in a Hospital Education (Persian)]. J Educ Strategies Med Sci. 2018; 11(3):158-65. [Link]
25. Haque M, Othman N, Lutfi S, Islam Z, Rahman N, Kibria GM, et al. Evaluation of Out-Patient Care Educational Environment of National Defence University, Malaysia utilizing the ACLEEM Inventory. J Basic ClinHealth Sci. 2018; 2:45-52. [DOI:10.30621/jbachs.2018.412]