Challenges and Problems of Clinical Medical Education in Iran: A Systematic Review of the Literature

AUTHORS

Amin Beigzadeh 1 , Nikoo Yamani 2 , * , Kambiz Bahaadinbeigy 3 , Peyman Adibi 4

1 Medical Education Leadership and Management Research Center, Kerman University of Medical Sciences, Kerman, Iran

2 Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

3 Medical Informatics Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

4 Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

How to Cite: Beigzadeh A , Yamani N , Bahaadinbeigy K, Adibi P. Challenges and Problems of Clinical Medical Education in Iran: A Systematic Review of the Literature, Strides Dev Med Educ. 2019 ; 16(1):e89897. doi: 10.5812/sdme.89897.

ARTICLE INFORMATION

Strides in Development of Medical Education: 16 (1); e89897
Published Online: January 1, 2020
Article Type: Review Article
Received: January 26, 2019
Revised: July 17, 2019
Accepted: July 20, 2019
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Abstract

Context: In order to improve the quality of clinical education, it is necessary to investigate the current situation in clinical settings and identify its problems. This step is the most important part of modifying a clinical education program and meeting learning goals. The purpose of this study was to identify the challenges and problems of clinical medical education in Iran.

Evidence Acquisition: This systematic review was performed to determine the challenges and problems of clinical medical education in Iran in 2017. In order to retrieve articles, the following keywords: Clinical education, bedside teaching, clinical teaching, teaching round, ward round, ward round teaching, bedside round, teaching round, medical education, clinical round, ambulatory education, clinic education, grand round, and education in emergency were searched in reliable Persian and English databases. Then, the articles related to the research objective were carefully reviewed and key information was extracted. Data were analyzed using MAXQDA software version 10.

Conclusions: The problems of clinical education are in different areas. Identifying these areas and planning for them can improve clinical education status, achieve educational goals, and provide medical students with a more effective education.

Keywords

Iran Systematic Review Challenges Clinical Education

Copyright © 2020, Strides in Development of Medical Education. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Context

In medical education, clinical education has a pivotal role due to providing learning opportunities for medical students. Clinical environments are important not only because of providing opportunities for students to learn but also they can provide feedback on educational, professional and personal development of medical students through the transfer of the experiences of an effective instructor (1). Approximately half of the educational time is devoted to clinical practice through exposure to patients in order to acquire clinical skills (2). Therefore, clinical education is core to medical education, where medical students with the help of a clinical teacher, present to the patients’ bedside and gradually acquire the skills required to solve the patients’ problems and perform clinical care. Clinical skills cannot be developed if this training does not provide appropriate learning conditions (3).

Thus, the acquisition of essential skills in medical education depends on the quality and quantity of training in clinical settings, and these environments must be continuously evaluated and monitored to ensure that the professional identity of medical students, interns, residents and fellows is shaped with appropriate clinical education. These groups are not only part of the medical staff and medical care team in the hospital wards, but are also receiving training and learning clinical skills while being exposed to patients (4).

Studies conducted in Iran concerning clinical education show that these trainings are not effective. It has been reported that there is a relatively deep gap in the process of medical education and clinical care practice, in a way that the existing clinical training does not provide students with the ability to attain clinical competence (5-7) and medical students have the most problems and dissatisfaction with clinical education (8). Research findings in Iran indicate that the level of complete or partial satisfaction of medical students in clinical education during the internship was 38.8% and the satisfaction rate in the three domains of clinic education, clinical education and theoretical education was 52.0, 52.0 and 78.0%, respectively (9).

Evidence suggests that clinical education is one of the most important and critical stages in medical students’ education that presents many challenges and problems, including time constraints, increasing numbers of students, fewer patients, inadequate resources for education, inappropriate clinical settings for education, opportunistic clinical education, lack of clear goals and expectations, passive observation rather than active learner engagement, inadequate monitoring and feedback, and limited opportunity for reflection and discussion (10).

A research conducted by Nair et al. examined the opinions of clinical teachers about the barriers to clinical education. In their study, medical teachers expressed factors such as the limited number of patients with good clinical symptoms, lack of patient collaboration, short duration of hospital stay, emphasis on community care, and lack of privacy in crowded wards as obstacles to having a proper bedside teaching (11).

In a study performed in London by Hendry et al., researchers described the problems of clinical education as “resource constraints, forgetting to teach basic skills in the clinical setting, time constraints, unclear goals and expectations, emphasis on memorization rather than problem-solving skills, passive observers instead of active participants, lack of adequate supervision and feedback and lack of informed patient consent” (12).

Therefore, identifying the challenges and problems in the clinical medical education is very important and improving the quality of clinical education requires constant review of the current situation and identification of strengths and weaknesses. Failure to identify barriers to clinical education and lack of planning to address them leads to a weakening of students’ professional skills and reduced efficiency of the educational system and quality of services to the community.

By identifying the existing barriers and removing them, steps can be taken to implement clinical education more effectively. This will lead to improved clinical education, achieving the goals of education and training qualified individuals to provide quality services to the community. The aim of this study was to identify the challenges and problems of clinical medical education in Iran.

2. Evidence Acquisition

This systematic review was carried out to identify the challenges and problems of clinical medical education in Iran during the first six months of 2017.

In order to achieve the research objectives, we searched the following keywords and their Persian equivalents: “clinical education”, “bedside training”, “medical education”, “clinical round”, “ambulatory education”, “clinic education”, “grand round” and “education in emergency” in national reliable databases such as the Scientific Information Database (SID), the Iranian Institute of Information Science and Technology (Irandoc), the Iranian Journals Database, the Barakat Knowledge Network System and Google Scholar.

In order to identify Persian-language articles, first the keywords were searched individually in each database and the search results were stored. Then, more searches were performed if possible by combining the keywords using the AND and OR operators with the Persian equivalents of the words: problems, challenges, medical student, intern, resident, medical teacher and patients.

In order to identify the English-language articles of Iranian authors, in addition to the national databases, the databases of PubMed, Cochrane, Embase, Scopus and Web of Science were searched. The keywords used in these databases included: teaching round, ward round, ward round teaching, bedside teaching, bedside round, training round, grand round, clinical teaching, ambulatory education and clinical education. These keywords were searched by combining them with the terms: problems, challenges, barriers, obstacles, medical students, externs, interns, residents, externship, internship, residency, clinical teachers, medical teachers and patients. The following is a sample search strategy for English databases.

“teaching round” OR “ward round” OR “ward round teaching” OR “bedside teaching” OR “bedside round” OR “training round” OR “grand round” OR “clinical teaching” OR “ambulatory education” “clinical education”) AND (“medical students” OR “externs” OR “interns” OR “residents” OR “externship” OR “internship” OR “residency” OR “Medical teachers” OR “clinical teachers” OR “patients”) AND (“problems” OR “challenges” OR “barriers” OR “obstacles”.

There was no specific timeframe for searching the articles, but we did try to include all the articles available (last searched 10.5.2017). The initial search was done individually by one of the authors, and then the accuracy of the search was examined by a medical librarian. It should be noted that in all stages of selection, the articles were reviewed by two evaluators and, if there were any differences, the cases were referred to a third party.

For the sake of thoroughness of the study, in addition to searching the databases, the references of all the articles meeting the inclusion criteria were reviewed. In order to verify the obtained information, all data were examined in two stages. In the first stage, a list of challenges and problems was prepared, and in the second stage, when coding was performed in MAXQA software, the challenges and problems were re-checked.

Concerning the review process, the search results of each database were stored separately in Excel version 2017 software. An initial search resulted in the identification of 1021 articles. After the search results were merged into one file, the articles were reviewed for duplication and the duplicates were removed.

Next, articles were reviewed by title and then abstract. Only unrelated articles that were not explicitly relevant to the research question were identified. In other words, to increase the search sensitivity, no suspicious items were removed during this stage. Finally, according to the inclusion and exclusion criteria, eligible articles were selected and their content was analyzed, and the challenges and problems related to clinical education were extracted.

2.1. Inclusion Criteria for Research Articles

We included studies examining the challenges and problems of clinical medical education, whose target group comprised of medical students, interns, residents, fellows, clinical teachers and patients. The included articles were original research studies with available full text in Farsi or English. The studies must have been performed in Iran and only in the field of clinical medicine.

2.2. Exclusion Criteria for Research Articles

We excluded conference papers, seminars, case reports, short reports, letters to the editor, commentary articles, review articles, review studies, researches performed among non-clinical medical students and non-clinical medical teachers, articles whose full text was not available, articles examining the basic science or the preclinical courses (only data related to clinical course was analyzed if the two courses were combined). Articles that evaluated the status of clinical education from the perspective of the participants as very good and good without any undesirable (bad or very bad) aspects were also excluded from the study. The average cut off point was considered as a measure for modification and change.

To summarize the articles, we used their full text. In order to reassure the relevance of the article to the research objective, the final part of the introduction, which stated the purpose of the paper, was considered. In this regard, special attention was paid to the important sections and strategies identified in the results section and some parts of the discussion. This was done by a member of the research team and to ensure the accuracy of the work, the categories and information extracted by another team member were reviewed. Also, someone outside the research team was asked as an external observer to examine the codings and categories.

In order to extract data from qualitative studies, all sections related to the results and discussions were studied several times by the researcher. Then, the sentences related to the challenges and problems were extracted from the text and saved in a separate Word file. These sentences included themes and categories extracted by the first author, the participants’ conversations in the results section, and the author’s conclusions.

In the case of quantitative articles with multiple choice questions, the challenges and problems were noted on the basis of what the author himself/herself stated. Also, if there was a table in the article, the items of the study questionnaire and those with a moderate, poor or very poor score were considered as barriers to clinical education and saved in a separate Word file.

The MAXQDA software was used to analyze the data; all the categories related to challenges were entered into the software and each challenge was considered as a code and the codes were compared according to their differences and similarities and classified into categories. The categories were given a title based on the related challenge (Table 1). The characteristics of the systematically reviewed studies are presented in Table 2. Data extracted from the articles included: the name of the first author, the purpose of the study, the type of study, the method of study, the target group, the sample size, and the study setting. It should be noted that we obtained a code of ethics (IR.MU.REC.1396.3.165) from Isfahan University of Medical Sciences.

Table 1. Themes, Categories, and Sub-Categories Obtained from the Literature Review of the Challenges and Problems of Clinical Medical Education in Irana
ThemeCategorySub-Category
Contextual challengesThe prevailing atmosphereAmbiguities
Dominant priorities
Management problemsEducation management
Educational regulations
Resources and facilities problemsInfrastructure
Educational-medical equipment
Educational-therapeutic environment
Challenges in the areas of clinical educationProblematic clinical roundsLow-quality rounds
Crowded rounds
Stressful rounds
Overcoming specialized education
Time limitation
Poor learning skills of learners
Limited educational opportunities
Patient role in clinical educationPoor educational content of rounds
Patient condition and diversity
Patient dissatisfaction
Failure to respect patient rights
Improper interpersonal interactions
Outpatient education problemsUndesirable clinic education
Lack of skills
Clinic crowdedness
Time limitation
Educational planning challengesWeakness in formulating and communicating goalsLack of familiarity with the course objectives
Unclear training objectives
Inadequate clinical teaching methodsNot using proper training methods
The application of traditional methods in teaching
Inadequate educational managementWeakness in defining professional duties
Poor planning
Theory and practice gap
Weakness in resources and contentInadequate scientific content in education
Lack of access to up-to-date scientific resources
Weakness in monitoring and evaluationEvaluation system
Teacher evaluation
Student evaluation
Methods of clinical evaluation
Challenges associated with clinical teachersEducational injusticeStudent discrimination
Inattention to the needs of students
Weaknesses in educational skillsLack of teaching skills
Lack of steadfast principles in education
Lack of professional empowerment and promotionUnfamiliarity of teachers to new educational concepts
Lack of a program to improve teacher skills
Occupational dissatisfactionTeachers' financial problems
Lack of motivation in teachers
BurnoutMultiple tasks and responsibilities
Challenges associated with studentsEducational dissatisfactionFinancial problems
Motivational factors
Inappropriate communicationsInappropriate behaviors
Lack of educational cooperation

aDue to the inductive nature of theme extraction, the first column is dedicated to the subcategories.

Table 2. Characteristics of the Systematically Reviewed Studies
SourcesPurpose of the StudyType of StudyStudy MethodStudy PopulationSample SizeStudy Setting
Ahmady et al. (13)Assessment of faculty members’ perceptions on identifying and addressing medical education challenges in order to improve educational goals and improve service qualityPhenomenologyQualitativeClinical teachers10Azad University of Iran, Mashhad branch
Rohani et al. (14)Determining the perspective of medical students, interns, residents, and clinical teachers concerning grand roundDescriptive-analyticalQuantitativeMedical students, interns, residents and clinical teachers237Iran University of Medical Sciences
Salari et al. (15)Determining interns’ satisfaction with the quality of clinical educationDescriptive - cross-sectionalQuantitativeInterns106Guilan University of Medical Sciences
Jameaazghandi et al. (16)Evaluating the quality of education at the bedside-Qualitative and quantitativeMedical students-Mashhad University of Medical Sciences
Iranmanesh et al. (17)Evaluating the educational quality of neurology departmentDescriptive - cross-sectionalQuantitativeInterns67Kerman University of Medical Sciences
Niroumand et al. (18)Evaluating the quality of clinic education from the perspective of medical studentsDescriptive - cross-sectionalQuantitativeMedical students and interns140Kermanshah University of Medical Sciences
Fani Pakdel et al. (19)Assessing the viewpoints of medical residents on different dimensions of the grand round program and satisfaction with these meetingsDescriptive - cross-sectionalQuantitativeResidents34Mashhad University of Medical Sciences
Ala et al. (20)Determining the factors affecting the quality of educational grand round from the perspective of the teacher teamDescriptive - cross-sectionalQuantitativeMedical students, interns, residents and fellows57Tehran University of Medical Sciences
Arabshahi et al. (21)Identifying the challenges of education in clinical roundsPhenomenologyQualitativeClinical teachers9Isfahan University of Medical Sciences
Jalalvandi et al. (22)Quality assessment of clinical educationDescriptive-analyticalQuantitativeMedical students119Kermanshah University of Medical Sciences
Sarchami et al. (23)A survey of medical students' viewpoints on the quality of clinical education-QuantitativeMedical students, interns and residents228Qazvin University of Medical Sciences
Azemian et al. (24)Investigating the obstacles and facilitators of clinical education and strategies for improving its qualityDescriptive-analyticalQuantitativeMedical students92Boushehr University of Medical Sciences
Maasoumi and Dastgiri (25)Evaluating the quality of training provided to interns in the emergency departmentDescriptive - cross-sectionalQuantitativeInterns100Isfahan University of Medical Sciences
Ghaffarifar et al. (26)Evaluation of interns' skills in clinics-QuantitativeInterns45Tabriz University of Medical Sciences
Gandomkar et al. (27)Determining the underlying factors affecting clinical educationPhenomenologyQualitativeClinical teachers8Tehran University of Medical Sciences
Anbari et al. (28)Determining medical students' satisfaction with the clinical education processDescriptive-analyticalQuantitativeMedical students and interns97Arak University of Medical Sciences
Anbari and Ramezani (29)Identifying barriers to clinical education and providing appropriate solutionsDescriptiveQuantitativeMedical students and interns84Arak University of Medical Sciences
Jamshidian et al. (30)Identifying the challenges of the clinic education programPhenomenologyQualitativeClinical teachers and interns14Isfahan University of Medical Sciences
Sharifi et al. (31)Quantification and quality of clinical educationDescriptive - cross-sectionalQualitative and quantitativeMedical students and interns54Yasouj University of Medical Sciences
Bazazi et al. (32)Assessment of Medical Students' Viewpoints about the Quality of Clinical EducationDescriptive - cross-sectionalQuantitativeMedical students and interns107Hamadan University of Medical Sciences
Siabani et al. (33)Identifying educational problems from the perspective of medical studentsGroup discussionQualitativeMedical students and interns24Kermanshah University of Medical Sciences
Nasri et al. (34)Identifying educational barriers, problems as well as problem-solving strategiesDescriptive - cross-sectionalQuantitativeMedical students and interns72Arak University of Medical Sciences
Adibi and Alizade (4)Determining the viewpoint of the care team concerning the impact of clinical rounds on patientsDescriptive - cross-sectionalQuantitativeMedical students and interns150Isfahan University of Medical Sciences
Khorasani et al. (35)Evaluating the quality of clinical education from the viewpoints of medical teachers and studentsDescriptive - cross-sectionalQuantitativeMedical students, interns, residents and clinical teachers180Mazandaran University of Medical Sciences
Roodpeyma and Salemi (36)Determining students' perceptions of clinical education programs in the pediatric departmentObservationalQuantitativeMedical students and Interns120Shahid Beheshti University of Medical Sciences
Zamanzad et al. (37)Evaluating the satisfaction rate and factors affecting the promotion of satisfaction with clinical trainingDescriptive-analyticalQuantitativeMedical studnets and interns77Shahrekord University of Medical Sciences
Adibi and Anjavian (38)Determining patients' viewpoints about internal clinical bedside roundsDescriptiveQuantitativePatients100Isfahan University of Medical Sciences
Zahedi and Amirmaleki (39)Investigating the effectiveness of general medical doctoral education from students' viewpointsSurveyQuantitativeMedical students162Tehran University of Medical Sciences
Fasihi Harandi et al. (40)Determining the quality of clinical education from the perspective of medical studentsDescriptive-analyticalQuantitativeMedical students and interns249Iran University of Medical Sciences
Hosseinpour et al. (41)Investigating interns’ training in surgery wardAnalyticalQuantitativeMedical students123Isfahan University of Medical Sciences
Ziaee et al. (42)Assessment of medical students' satisfaction with the quality of clinical educationDescriptive - cross-sectionalQuantitativeMedical students250Tehran University of Medical Sciences
Mortazavi and Razmara (43)Assessment of medical students' satisfaction from different aspects in different educational positionsDescriptive - cross-sectionalQuantitativeMedical studnets and interns400Isfahan University of Medical Sciences
Fekri and Sarafinejad (44)Assessment of medical education status in three educational groupsCross-analyticalQuantitativeMedical studnets and interns239Kerman University of Medical Sciences
Karimi Monaghi et al. (45)Search, describe, and interpret medical students' understanding of clinical learningGroup discussionQualitativeMedical students20Mashhad University of Medical Sciences
Avizhgan et al. (46)Evaluating the quality of outpatient education from the perspective of medical students to improve quality of educationDescriptive - cross-sectionalQuantitativeMedical studnets and interns180Isfahan University of Medical Sciences
Esteghamati et al. (47)A survey of residents and attending experiences and views on learning in the clinical environmentPhenomenologyQualitativeResidents and attending30Tehran University of Medical Sciences
Haghani et al. (48)Assessment of faculty members' experiences regarding training in clinical roundsPhenomenologyQualitativeClinical teachers9Isfahan University of Medical Sciences
Rezaee and Ebrahimi (49)Identifying factors affecting medical students' learning in clinical environments-Qualitative and quantitativeClinical teachers and residents184Shiraz University of Medical Sciences
Mosalanejad (50)Evaluation of quality and barriers to education at the bedsideCross-sectionalQuantitativeClinical teachers50Jahrom University of Medical Sciences

3. Results

In the initial search, 1021 articles were found, and after removing duplicates, 593 articles were reviewed by title and abstract (546 Persian and 47 English). Of these, 492 were removed and 101 were selected. Next, based on the full text and the inclusion criteria the final separation was performed and 39 articles were included in the study. Of these, 28 were in Persian and 11 in English. The content of these articles was analyzed and the challenges and problems of clinical medical education were examined. The process of entering articles into the research is shown in Figure 1.

The process of entering articles to the systematic review
Figure 1. The process of entering articles to the systematic review

In terms of the type of studies included in this systematic review, there were 28 (71.8%) articles with quantitative methodology, 8 (20.5%) with qualitative methodology and 3 (7.7%) with quantitative-qualitative design.

Concerning the views of different research groups, 28 (71.8%) articles explored medical students’ views, 5 (12.8%) articles investigated clinical teachers’ views, 5 (12.8%) articles explored the opinions of students as well as teachers and 1 (2.6%) article examined patients’ views about the challenges of clinical medical education (Table 2).

By perusing the data, 498 initial codes (semantic units) were extracted from the articles. The codes were entered into the MAXQDA software for ease of work. Then, the common items and similar codes were merged and the categories were grouped in a theme. Based on the findings, the challenges of clinical medical education in Iran were classified into 5 themes, 18 categories and 49 subcategories.

4. Discussion

The main mission of medical universities is to train specialized staff to provide high-quality care to the community. In this regard, it is necessary to identify the challenges and problems of educational programs in order to improve the current situation by formulating and implementing systematic programs.

This will lead to improved achievement of the goals of education and training of skilled people and improvement of the quality of health services throughout the country. The current systematic review has led to the identification of a number of challenges related to clinical education in Iran. The themes derived from data analysis are discussed in more details below.

4.1. Challenges and Problems of Clinical Medical Education in Iran (498 Codes)

4.1.1. Contextual Challenges

This theme comprised 96 (19.3%) codes and three categories: prevailing atmosphere (16 codes), management problems (20 codes), and resources and facilities problems (60 codes).

The clinical education environment is a stressful environment for medical students. This environment of an unpredictable nature (21, 27) makes it difficult for students to be taught at patient bedside. International research has referred to factors such as students' fear of patient exposure (51) and fear of presence in hospital wards without the presence of teachers (52), which are consistent with the results of the present study. Also, the results of some studies have shown that the future of medical students is ambiguous and worrying for them (13, 30, 34).

In a study, 30% of students did not show interest in the medical profession (53), which is consistent with the results of the present study. It seems that by raising students' awareness of the human aspects of the medical profession and expressing existing job opportunities and providing counseling, some of their concerns can be mitigated and a positive attitude can be instilled in them. Among the other issues affecting the current state of clinical medical education are the prevailing priorities in the medical education system, treatment priority over education, education being affect by medical and research responsibilities (47), stronger role of research compared to education (27), priority of residency examination over education (27, 30) and lack of attention to student education at lower levels of medical education such as medical students and interns compared to senior students (26, 27, 47). In another study, priority was given to health care over bedside education (54).

Other problems with clinical education include inadequate educational management and lack of educational regulations. The findings of the literature review indicate that lack of management is the source of numerous problems such as interpersonal and interdepartmental relationships (27), incorrect planning (44) and excessive workload in health care (15, 27, 36, 37, 49).

Teaching management principles, planning by experienced people, and using effective management techniques can partially alleviate the existing management problems. The clinical education system should provide the responsibilities associated with everyone involved in the education process. These include lack of job descriptions for teachers and students (30), lack of clarity of staff duties towards students (29), and lack of job descriptions for students at the beginning of the course (34).

Other issues that have affected clinical education are resource problems and facilities. The results of the present study showed that the necessary infrastructures such as lack of access to the Internet and web-based educational resources (18, 21, 26), lack of availability and updating of library resources (31, 34) and lack of access to educational journals (31) are important things that can lead to student dissatisfaction.

Therefore, medical school education authorities should take the necessary steps to provide appropriate educational facilities. Masic et al. in a study in Sarajevo found that students considered the most important factor in improving the quality of medical education as having up-to-date educational facilities (55). On the other hand, lack of physical resources such as inadequate library space (34), insufficient number of computers in hospitals (31) and lack of human resources such as experts and faculty members (26, 27, 33, 37) are among the factors affecting the quality of clinical education.

International research has referred to the shortage of staff (faculty) (56) and nurses (57) in clinical education. Findings regarding the physical condition of the clinical education environment indicate that hospitals are facing a shortage of educational facilities (13, 18, 27, 31, 34) and equipment (15, 23, 24, 32, 49).

Ramani et al. cited one of the barriers to clinical education being the lack of a negatoscope for viewing radiology images when discussing with students at the patient's bedside (58). In addition, lack of medical equipment and their inadequacy (21, 30, 43) and lack of educational aids (22, 25) disrupt the teaching process. One of the most important issues in clinical education is paying attention to the appropriate educational environment when teaching students. Given that most of the time spent in the patient's bedside is devoted to inpatient departments, educational clinics, or clinical rounds, these environments should be standardized and proportionate to the number of students, but evidence suggests that educational space is limited (18, 27), and there is no correlation between educational spaces and the number of students (13).

The results of the study conducted by Obeidi and Motamed in Bushehr also showed that the lowest score was related to the lack of proportion between the number of students and physical space in the internship wards (59). Research results have shown that the physical space of the wards (13, 29, 43, 46), clinics (17, 32, 35) and clinical rounds (21, 22, 28, 42, 48) are inadequate for teaching. International research has referred to the lack of space in the patient rooms (60), small rooms (61) and lack of room for pre- and post-clinical rounds (56) which is consistent with the results of the present study.

4.1.2. Challenges of Clinical Education Areas

This theme consisted of 184 codes (37%) and had three categories: Problematic clinical rounds (114 codes), patient role in clinical education (44 codes) and outpatient education problems (26 codes).

Most of the codes extracted from the literature review were related to the challenges of clinical education and the category of problematic clinical rounds. Undesirable process of clinical rounds (4, 38), simultaneous working round and teaching round (21) and failing to make appropriate and timely decisions on how to conduct teaching rounds on the part of the relevant authorities (20, 41) and, on the other hand, lack of proper participation and student discipline (14, 19-21) and their presence at different levels in rounds (21, 27, 47) lead to poor quality of education (14, 19, 29, 42) and ultimately affects the effectiveness of education (45, 49).

One of the main and important problems of clinical rounds in Iran is the crowdedness of rounds due to the large number of students in clinical departments or rounds during training (22, 24, 38, 44, 45, 48). This factor creates a noisy and crowded environment (21, 50), which results in disorder and dissonance in student education (44). International studies have referred to crowded rounds (62), large numbers of students at the clinic (63), and the presence of students with varying levels in rounds (64).

Research results show that the crowded environment of clinical rounds prevents the effectiveness of training in clinical rounds (11, 64, 65). The physical and psychological conditions of the clinical teaching environment should be such that it provides a good basis for students' thinking and practice. Having stress to deal with the patient alone and the fear of working in the real environment (45) creates an overwhelming amount of stress. Proper student interaction with the instructor and clinical teaching environment and receiving adequate social support from residents and teachers also play an important role in modifying this environment and enhancing clinical learning (45, 49), which has received little attention (23).

Also, cases such as dispersed and inconsistent discussions at the bedside (4, 38), specialization of teaching in clinical rounds (20, 21, 27, 33, 47), inadequate level of students with specialized and sub-specialized fields (27, 30), inappropriateness of examination of complex clinical cases for interns (26), limited clinical training time (27, 31, 50) and lack of time to discuss patients in clinical rounds (19, 27) lead to disruptions in student learning and double the necessity of creating specific frameworks and criteria for conducting clinical rounds.

Numerous studies have pointed to the lack of time for bedside education (11, 56, 57, 62, 65-67), which is consistent with the results of the present study. The unfavorable status of clinical skills education (29) and the low level of students' learning from the provided clinical education (25, 44, 45) indicate weaknesses in examination (21, 36), treatment (15) and patient management (26).

Although clinical education provides students with the most important opportunities for bedside learning of medical science, the results of literature review show that educational opportunities, such as visiting and treating patients independently (17, 35), clinical decision-making in the treatment process (45) and the opportunity to apply knowledge and skills in patient care (24) are not sufficiently provided to students in the clinical course. According to Wiseman, medical students need to be allowed to observe and participate in clinical counseling and patient visits to develop their attitudes and skills as an effective and evolving physician (68).

Other considerations that greatly affect students' learning quality are the problems associated with educational content of the rounds. The content of educational rounds is not of sufficient quality, with less attention being paid to such topics as patient-related social aspects in rounds, critical thinking, physiopathology, differential diagnoses, diagnostic indices, prevention and treatment indices, and follow-up (14, 20). This has led to a decrease in the educational impact of clinical rounds on students' success in the

4.1.3. Objective Structured Clinical Examination (OSCE) and Clinical Skills of Students (19)

The role of the patient in clinical education is very significant; insufficient diversity of patients in the inpatient departments (43), limited clinical cases (24, 27) and the sudden deterioration of the patient's status during rounds (21), affect clinical education (50). Evidence suggests that patient-related concerns are ignored during the clinical education process. Given the large number of students in clinical rounds, especially in the intern group, it is not clear to the patient who is the physician in charge when students and teacher attend at the bedside. The resultant is an insecure feeling concerning treatment by someone other than the treating physician (4, 38).

On the other hand, crowded rounds cause fatigue in patients due to examination by multiple medical students (27, 30), high frequency of visits (4, 21) and prolonged visits (4). For this purpose, it is recommended that group visits be performed at one time to reduce the number of visits per clinical round. In international studies, patients' concerns about long-term presence of students at bedside (66) and physical examinations (52, 61) have been mentioned.

Not paying enough attention to the patient's privacy (6, 21, 50) and being examined by a group of people in rounds (4, 38) induce unpleasant feelings. It is necessary to talk to the patient before the clinical round begins and inform them of students’ education at their bedside, but the findings show that these are ignored during rounds and even those present in the round are not introduced to the patient (16).

Patients' rights being ignored (45, 48), including lack of patient consent during clinical rounds (21), lack of patient consultation in medical decisions (4, 38), lack of sufficient and comprehensible explanations for the treatment process (4) and failure to provide explanations on the treatment and the concept of the round for the patient (38) are among the factors that lead to patient dissatisfaction. Numerous studies have indicated the importance of patient privacy (61, 69, 70)

In order to prevent dissatisfaction in patients, it is advisable to give them brief explanations about the disease and its treatment. Physical and psychological harms to patients and lack of proper communication with them (21, 39) are some of the factors that cause a great deal of dissatisfaction during clinical rounds, leading to inappropriate interpersonal interactions and lack of co-operation for bedside education (50).

According to the outcome-based education approach, any higher education system must train students according to their future career needs (71). In the medical field, this is achieved through outpatient and clinic training, as more than 50% of clinical practices of interns are dedicated to this matter (72), but evidence suggests that all students do not participate adequately in clinic education (32), which can be due to inappropriate clinic education (35, 37), lack of respect for outpatient medicine (33), limited educational opportunities in outpatient clinics (47), and lack of a steadfast principle in education (30).

The busyness of clinics (18, 35) and time constraints in outpatient education (30, 46, 47) also affect students' educational opportunities and impede the acquisition of necessary skills (28, 30, 35) in this stage of clinical education. The results of studies in developed countries have reported relatively low satisfaction with clinic education (73). Evidence indicates lack of attention to clinic education in the society and the lack of a coherent plan to improve clinic education compared to advanced countries. Since outpatient clinics have a greater share of assimilating future working conditions of the students than the inpatient departments in terms of the variety and prevalence of illnesses in the community, more careful planning is needed by the authorities.

4.1.4. Educational Planning Challenges

This theme consisted of 131 codes (26.3%) and included five categories: weak compilation and information briefing (10 codes), inadequate clinical teaching methods (11 codes), inappropriate educational management (57 codes), resource and content weaknesses (16 codes) and inadequate monitoring and evaluation (37 codes).

Uncertainty and failure to provide educational goals to students at the beginning of the course (15, 22, 33, 35, 40) is due to a weakness in formulating and informing educational goals. As a result, the clinical education minimum is not specified for students (28, 29) and their learning is not in line with predetermined educational goals (22). Therefore, clinical education needs to be planned according to predetermined goals and announced to the students at the beginning of each course and each lesson.

The inadequacy of clinical teaching methods (28, 43, 50) and the use of traditional teaching methods (33) lead to inactivity of students during training. Therefore, it is recommended that new, student-centered teaching methods be continuously evaluated and analyzed by medical education experts and the most fective be identified and taught in on-the-job training workshops to medical teachers.

Lack of awareness and uncertainty of students' clinical responsibilities (4, 39, 49) and irrelevant tasks (30, 45) indicate weaknesses in defining students' professional duties. This results in less commitment in interns towards patients. On the other hand, the low level of educational needs assessment (29) and lack of attention to educational needs in planning (21, 32) exacerbate this problem.

The results of literature review show that proper planning for clinical education is not done in a way that maximizes student learning and training. This lack of planning leads to inconsistency in training programs (15, 36), problems with scheduling educational classes (41, 45), decreased learning and increased fatigue among students (45).

One of the important issues in the student learning process is the integration of theoretical and practical lessons at the bedside. The gap between theoretical and practical knowledge at the bedside and the discrepancies between the two (22, 30) should be taken into account in educational planning. Research findings show that learning experiences do not meet students' professional needs (33, 45) and place greater emphasis on teaching theoretical concepts rather than clinical education and clinical skills (31). Therefore, consideration should be given to tailoring and bringing theory lessons into practice in educational planning. Consistency of theoretical courses with practical skills in student education has been reported as one of the factors having an impact on the effectiveness of educational programs (74).

Theories learned must be essential and applicable and extracted from up-to-date scientific sources (21, 30, 33). This requires the availability of the scientific resources needed for further study of students (16) and the relevance of the scientific content in clinical education (25, 30, 41). This is especially important at the bedside so that students can improve their knowledge using up-to-date scientific resources, but evidence suggests that up-to-date scientific resources are not used in clinical education (40) and access to educational resources and journals is limited (18, 26).

Monitoring and evaluation should not be neglected to enhance the quality of clinical education and identify the strengths and weaknesses of the educational system. According to the studies, inadequate evaluation system (15, 30) and insufficient supervision over the clinical education process (33, 49) have a negative impact on students' learning and teaching process. Lack of objective evaluation of teachers’ educational activities and clinical education program (21), inadequate student evaluation methods and lack of specific criteria (15, 33), students' dissatisfaction with the end-of-course evaluations (32) and low level developmental evaluations of students during the course of clinical education (29) indicate the absence of an efficient and effective evaluation system.

These objectives are achieved when education management develops a clear plan for a reasonable evaluation system. The results of the study conducted by Fakhari et al. showed that more than 50% of interns were dissatisfied with the evaluation methods and only 28% were satisfied with the evaluation methods of their skill and ability (75). What is important in the evaluation process is providing appropriate feedback to students, but unfortunately, appropriate feedback on students' educational activities is not provided (24, 26, 39, 49). In addition, the evaluation methods used are unfavorable (29, 49) and have low validity (29).

4.1.5. Challenges Related to Clinical Teachers

This theme consisted of 62 codes (12.4%) and had five categories including inequality in education (12 codes), weaknesses in educational skills (21 codes), empowerment and professional promotion (9 codes), job dissatisfaction (11 codes) and burnout (9 codes).

Inconsistencies in education may include disregard of interns in the clinical training process (18), lack of involvement of interns in the training process and clinical rounds (26), inappropriate allocation of educational activities among students (21), disregard of student needs (39), students' lack of access to teachers informally (39), lack of discrimination between active and inactive students (30), discrimination between medical students and interns (45), student discrimination on the number of on-call shifts (45), lack of access to a clinical teacher for troubleshooting and answering student questions (29), disregarding student opinions (3), disregarding students and their problems (44), and inadequate division of students between teachers (21).

Inappropriate training provided by clinical teachers and their inappropriate performance can be due to insufficient mastery of teachers and lack of necessary skills in performing clinical-educational role (27, 34, 45, 50), inadequate teaching experience (42), the lack of ability to manage and control the discussions in clinical rounds (40), the lack of regular presence of professors in the morning report sessions (40) and the lack of steadfast principle in teaching and at the bedside (33).

It should be noted that implementing the teaching process through competent and efficient mentors can enable students to make the most of their abilities. The results show that teachers with sufficient clinical knowledge and skills can play an effective role in teaching students. These teachers, as professional role models, play an important role in the growth of students and empowering them to embark on their future careers (1, 76-78). International studies reported lack of training skills (61), lack of clinical skills and knowledge (60), and lack of experience in bedside clinical training (65), which is consistent with the results of the present study.

Ramani et al. cited barriers to clinical teaching as well as the fear of young teachers failing to deliver good clinical education. Clinicians believed that empowering these people is not considered important in the educational setting (58). In order to have a high quality and effective clinical education system, empowerment of clinical teachers should be considered and planned because of their lack of knowledge of existing programs for professional development (13) and lack of adequate training and curriculum (13), leading to a disruption in education and presenting scientific and practical concepts in an incorrect way.

Literature shows that clinical teachers are not familiar with teaching methods and new educational concepts to perform their educational role (27) and no workshops are held to teach these skills (30). Certainly, empowerment courses can help to promote clinical teachers. Along with the empowerment of teachers, other motivational aspects must also be considered. Uncertainty about the employment status of some teachers (30), financial problems (21, 27) job dissatisfaction and lack of motivation due to some inequalities and inconsistencies in the existing administrative structure can lead to discouragement of teachers which impedes their career development (13, 30).

Numerous studies have pointed to the lack of teachers' motivation in student education (30, 35, 40, 50), which is one of the important factors in reducing the quality of clinical education. In their research, Hendry et al. expressed lack of funding and, more importantly, lack of education and lack of attention to educators as inhibiting factors for teacher motivation (12). The study done by Razavi Asl showed that salaries and benefits, job promotion, etc. are the main factors affecting job satisfaction (79).

Numerous studies have pointed to the lack of teachers' motivation to teach students (51, 57, 58, 63, 67). These finding is in line with the present study. Many duties and responsibilities and the overwhelming workload of clinical teachers apart from teaching (21, 30, 47) lead to excessive fatigue and burnout (13, 24, 27) and have an important role in reducing the quality of education. Most studies published in the field of clinical education have cited the high volume of clinical duties and lack of training for teachers regarding their teaching role (11, 80-85), which is consistent with the findings of the present study. Similar studies have also highlighted the clinical and research responsibilities of faculty members that affect students' clinical education (58, 60, 64).

4.1.6. Student-Related Challenges

This theme contained 25 codes (0.5%) and had two categories including educational satisfaction (12 codes) and inappropriate interactions (13 codes).

Few studies have examined the role of students' financial problems and their impact on learning, but undoubtedly the burden of financial problems and their consequences cannot be ignored (21, 30). Another challenge related to students' educational dissatisfaction is lack of motivation. Studies show that students do not have sufficient motivation for education (13, 24, 27, 30, 44, 50). Students' lack of motivation in both learning and clinical practice can sometimes be covered by encouraging them to do group work (39). This creates a sense of belonging and being seen as part of the medical team and enhances the motivation and dynamics of students (45). Many international studies indicate a lack of learning motivation among students (51, 56, 62, 63), which is similar to the results of the present study.

Overall, considering that one of the important factors in education is having a passion for learning, attention should be paid to planning priorities of medical education centers. An inadequate interaction among students, teachers, and staff in the medical field is a major obstacle in the creation of a healthy learning environment. Lack of respect and mutual trust among different groups involved in education (16, 24, 34, 40, 45) leads to unhealthy workplace and mental environment which in addition to undermining the performance of each group, also underpins the overall effectiveness of clinical education. According to the results of the Zygmont and Schaefer, clinical education for students should be conducted in collaboration with clinical staff (86).

In the study by Aga Khan et al. in Urmia, 75% of medical students rated the performance and cooperation of medical staff as poor and 21.4% rated it as moderate and only 3.6% rated it as good (87). Fear of humiliating behaviors of teachers and staff has always been one of the concerns of students in clinical education and is one of the serious barriers to self-esteem and student learning in the clinical setting. This demonstrates the importance of educational authorities' attention to providing an appropriate teaching environment.

One of the most important aspects in this regard is the role that clinical teachers play in teaching students because their professional behaviors are monitored by students and students expect their professors to be responsible in their professional interactions and have appropriate professional communication with their students, patients, and other health care providers (88).

The present study emphasized the need to identify challenges and problems in order to improve quality in clinical medical education. By reviewing articles in the field of medical education, several challenges such as contextual challenges, challenges in clinical education, educational planning challenges and challenges associated with faculty and students were identified. Careful planning is expected to help solve these problems, as neglecting this can lead to a weakening of students' professional skills, a decline in the efficiency of the educational system, and a decline in the quality of service to the community. The findings of this study can help policy makers in medical education, medical university officials at different levels, and faculty members in implementing interventions and decision making to enhance the clinical education process.

Acknowledgements

Footnotes

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