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      Applying Adult Learning Theories in Improving Medical Education in Nepal: View of Medical Students

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          Abstract

          Entering into medical school from practicing or experiencing pedagogic teaching in high school and undergoing a huge transformative process during the 5 years to come out as adults requires self-reflection on what university or medical school has taught us. Adulthood is inevitable in medical school and thus, a question remains, would andragogic teaching be better for me? As an adult medical student, do I learn in a better way than attending the lectures online or in the lecture hall itself? These questions have randomly crossed our minds and the COVID-19 pandemic has made it even more significant. Andragogy took its shape during the 1980s when Malcolm Knowles further elaborated the concept of andragogy. 1 It states that adults are: Independent and self-directing Have diverse experiences Integrate learning as a demand of their everyday life Are more interested in problem-centered approaches Are motivated by internal rather than external drives Lockdown and self-reflection have made a whole new paradigm shift on what we thought learning was. We generally have different experiences in our lives based on the region of the world where we live, but the “fear of COVID” has been an experience shared by people all around the world. It made humanity unite and understand what everyone was going through. Many webinars, open-access lectures, talks and symposium made realization dawn that we can learn on our own, the things we feel there is a need to learn. The world suddenly opened up for us, and learning happened in a way we wanted to learn, besides the university's online lectures. This is what the personal definition of andragogy was for us. APPLYING ADULT LEARNING THEORIES INTO OUR MEDICAL EDUCATION OPTIMIZING STUDENT INVOLVEMENT IN DECISION MAKING AND PLANNING AMEE (Association for Medical Education in Europe) advocates students' engagement in management, provision of academic programs and their involvement in the local and academic community, and a medical curriculum for the students and by the students. The optimal model is to achieve student and teacher equity in learning. We still have a long way to ensure student involvement in medical education but paving the way is paramount to uplift the health care system of Nepal. SELF DIRECTED LEARNING (SDL) SDL (Self-directed learning) has been the core of adult learning. A study done in a medical college in Nepal, which judged undergraduate students' readiness to take up SDL (Self-directed learning), showed that 72.7% were ready to incorporate self-directed learning in their education. 2 This has a personal implication for us too. During the lockdown, as a regular program for Walter E. Dandy Neuro Club of Nepal, we had set up a simulation session for students of 1st and 2nd year of medical school to conduct a program on “ArterioVenous Malformation.” The neurosurgery topic seems vast and complex because it being a super specialization. However, the students presented it wonderfully with all the evidence-based approaches, surgical techniques, and the recent trials being conducted on this topic. This made us self-reflect on how much of learning we were doing in medical school and how capable we are of learning independently. PROBLEM BASED LEARNING “Adult learning is self-directed and interested in problem-centered approaches with the application of their learning to solve immediate problems.” The application of Problem-based learning in our curriculum was adapted from the McMaster University of Canada in 1960. 3 Problem-based learning is a teaching method that applies the same principles of andragogy. A study done in CMC (Chitwan Medical College) found that 78% of students recommend it as being better than the lectures. 4 It is a learning method based on the principle of using problems as a starting point for acquiring and integrating new knowledge. It is a way of dealing with a problem by integrating diverse aspects of a case, setting learning goals and coming up with a solution; this encompasses all matters of adult learning. It makes the learning environment more conducive and humane and employs a very important self-reflection tool for learners. Subjectively speaking, the Problem Based Learning that we had in the 2nd year of medical school in NAIHS was an effective way of learning to find out answers for ourselves. Actively involving in the learning process made learning easier, applicable and self-paced. SKILL-BASED TEACHING Skills are indispensable for medical students. The actual response is very different from knowing the theory. Skills are not focused enough for medical students in Nepal and are set aside for internship, a yearlong posting in the hospital when we have actually formally completed our medical education. Imparting skills like venepuncture, cannula insertion, delivering a baby, putting on an endotracheal tube, performing CPR, and taking a nasopharyngeal swab could be imparted to medical students from the curriculum itself by employing various techniques like using mannequins and cadavers. The possibilities are endless. BUILDING COMMUNICATION SKILLS BY SIMULATION Medical students need to be taught skills and professionalism; this ultimately amounts to improved patient outcomes and better healthcare systems for Nepal. “Medical paternalism'' Doctor knows best is changing with the increased economic growth in the region. 5 It has been shown in a study that medical students' empathy levels plummet from the time they entered medical school. 6 Amongst all this, the use of simulation to teach medical students communication skills and counseling is of utmost importance. Many diverse topics could be learned in smaller groups like breaking bad news, empathy, doctor-patient relationship. This helps gear students towards familiarity when encountering such situations and makes learning active and fun via role-plays and discussion. FUN TRIVIA AND QUIZZES Quizzes use the active recall technique, which serves to enhance retention. Many online software that came to light during this lockdown; like Menti and Kahoot, make medicine something to be learned while having fun and their interface also provides a place to connect with a global audience and, in this case, medical students from many different countries. WAY FORWARD Adult-based learning can have a lot of implications: for it is a concept that empowers adults to study on a priority basis, which they decide, based on their learning plan, their experiences, immediate need, or interest. This certainly improves outcomes. A lot of experience sharing, practical discussion and horizontal transfer of knowledge with collaboration is the ultimate way to learn because learning is and should be fun and impactful. The burden lies on us students too. In a rapidly evolving global era, we need to evolve. We need to feel we are a part of adult learning and start paving a way to achieve student-teacher equity and develop a concept of medical curriculum for the students.

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          Cross sectional assessment of empathy among undergraduates from a medical college.

          Empathy is essentially a desirable quality among clinicians and can be developed during medical education. Studies from outside India have shown that higher empathy is related to better competency and choice of specialty may be related to empathy levels in them. Change in empathy levels among undergraduate medical students with progressive training has been often ascribed to reasons such as curriculum content, timing of clinical rotations. Gender differences in empathy levels also vary among different countries. Since many of such factors differ in India there is a need therefore to understand empathy and its correlates among medical students in India.
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            Doctor-patient relationship: from medical paternalism to enhanced autonomy.

            J J Chin (2002)
            For centuries, physicians have been allowed to interfere and overrule patient's preferences with the aim of securing patient benefit or preventing harm. With the radical rise in emphasis on individual control and freedom, medical paternalism no longer receives unquestioned acceptance by society as the dominant mode for decision-making in health care. But neither is a decision-making approach based on absolute patient autonomy a satisfactory one. A more ethical and effective approach is to enhance a patient's autonomy by advocating a medical beneficence that incorporates patients' values and perspectives. This can be achieved through a model for shared decision making, acknowledging that though the final choices reside ultimately in patients, only through physician beneficence can the patient be empowered to make meaningful decisions that serve them best. For such a model to function effectively, the restoration of trust in doctor-patient relationship and the adoption of patient-centred communication are both crucial.
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              Attitude and perception of undergraduate medical students toward the problem-based learning in Chitwan Medical College, Nepal

              Background Problem-based learning (PBL) was introduced into Basic Medical Sciences early in the 1980s at Tribhuvan University (TU), Nepal, followed by other universities where didactic lecture method was still followed as the main teaching strategy. Despite gaining its popularity worldwide as integrated teaching learning method, PBL is not given importance in Nepal. This study aimed to assess the attitude and perceptions of undergraduate medical students regarding learning outcomes of PBL and to know their views about role and qualities of effective tutors for its successful implementation. Methods This descriptive study was based on a self-administered questionnaire. The first part of the questionnaire measured students’ perception and attitude toward benefits of PBL and the second part measured students’ perception about role of PBL tutor. Bachelor of Medicine and Bachelor of Surgery (MBBS) first year (2014/2015 academic year) students at Chitwan Medical College, TU, were asked to express their opinions about the importance of learning outcomes by rating each statement on a five-point Likert scale and the responses were combined into three categorical variables: “agree” (strongly agree plus agree), “neutral”, and “disagree” (strongly disagree plus disagree). Data were analyzed using SPSS version 21.0. Results Approximately 85.5% participants agreed that PBL is an interesting method of teaching learning. Most of them (86.7%) accepted that PBL is an interactive and a mutual learning method and improves self-directed learning (83.2%). Although 78% had recommended it better than lecture, many (54.2%) pointed it out as a time-consuming method. The participants were also highly rated (80.5%) to the statement - the tutor’s role in enhancing the constructive active learning and maintaining good intra-personal behavior. Conclusion Student’s attitude toward PBL was positive. They highly appreciated the roles of a tutor as facilitators and motivators for proper activities in PBL session. PBL sessions were considered effective in improving students professional knowledge and refining problem-solving and self-directed learning skills along with enriching teamwork experience.
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                Author and article information

                Journal
                JNMA J Nepal Med Assoc
                JNMA J Nepal Med Assoc
                J Nepal Med Assoc
                JNMA
                JNMA: Journal of the Nepal Medical Association
                Journal of the Nepal Medical Association
                0028-2715
                1815-672X
                February 2021
                28 February 2021
                : 59
                : 234
                : 210-211
                Affiliations
                [1 ]Nepalese Army Institute of Health Sciences , Sanobharyang, Kathmandu, Nepal
                [2 ]National Medical College and Teaching Hospital , Birgunj, Nepal
                Author notes
                Correspondence: Ms. Prarthana Subedi, Nepalese Army Institute of Health Science, Sanobharyang, Kathmandu, Nepal. Email: prarthana.subedi.ps@ 123456gmail.com , Phone: +9779808750938.
                Article
                10.31729/jnma.5292
                8959234
                34506474
                afe13a24-2241-4fc3-9b43-beef7ef8184a
                © The Author(s) 2018.

                This is an Open-Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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