The Revised Regulations on Graduate Medical Education, Part II 2019 have created an opportunity in the MBBS program providing students options to do Electives. An Elective is a learning experience created in the curriculum to provide an opportunity for the learner to explore, discover and experience areas or streams interest in the profession (MCI, 2020).

Electives provide the student with opportunities for diverse learning experiences, to do research/community projects that will stimulate enquiry, self-directed, experiential learning and lateral thinking. Two months are designated for elective rotations after completion of the examination at end of the third MBBS Part I and before commencement of third MBBS Part II. It is mandatory for the students to do an elective (MCI, 2020).

Curriculum Implementation Support Program (CISP) Module on Electives stresses on the provision for evaluation of the program based on information from all stakeholders, in order to evaluate the effectiveness of the program and need for modifications and improvement.¹In this context, student feedback is a valuable source of information for taking measures regarding curricular reform, resource allocations, and improvement in the teaching–learning cycle (Rauf, 2014).

The most common method used in obtaining students’ feedback has been structured questionnaires (Huxham, 2008). If an end-of-module questionnaire is able to capture all important points, then this approach is adequate; however, if the information gathered through questionnaires does not serve the purpose, the institute should use appropriate tools that are useful in their own school context (Archer, 2010).

Qualitative data can be useful for promoting positive and desirable improvements in the curriculum. In this regard Focus groups forms a popular method for collecting qualitative data, as the method capitalizes on the interaction of the group members, a feature that differentiates it from other methods of qualitative data collection. It provides an opportunity for the participants to reflect upon their responses hence laying emphasis on analysis of information rather than only data gathering. The information gathered in a focus group is subject to the phenomenon of ‘groupthink’ wherein interactions within the group also become the subject of analysis (Chioncel, 2003). The questions are not addressed to each individual, and the data comes from the group interaction (Rauf, 2014).

Electives was used for the first time in the Indian Medical Curriculum. So, in our study we wanted to use focus groups as a tool to obtain in-depth information regarding students’ experiences and find any barriers in implementing the new Module on Electives in the New Competency Driven Medical Curriculum.

OBJECTIVES

1. To Evaluate the Use of Focus groups for Obtaining Feedback on the new Module on Electives in the New Competency Driven Medical Curriculum
2. To Explore the Trustworthiness and Representativeness of data obtained through Focus groups
3. To Find out the Barriers in Implementing Focus groups

MATERIALS AND METHODS:

STUDY DESIGN:

Type of study: “Exploratory Descriptive Study”.

Study period: 14^th Nov 2024 to 14^th Jan 2025.

Study population: III Year Part-1 MBBS students

Study place: Medical College & Hospital

Sample size: 126 students

Data collection:

Three learning experiences from each block of electives, were identified from which student’s feedback were collected through focus groups: Block 1: One learning experience from Laboratory, Second learning experience from community outreach activities and third experience from the research activities. Block 2: One learning experience from Clinical specialties, Second experience from Super-specialties and third experience from the urban and rural health centre experiences (MCI, 2020).

In addition to principal investigator, two other faculty members were identified as co-researchers as well as moderators. These three faculty members were familiar with conducting focus groups and were not be part of the courses that were included in this study (Rauf, 2014).

Design/Structure of Focus Groups (FG): Three parallel focus groups of 7 students each were conducted at the end of each of the three learning experiences from each block of electives (eighteen groups in total). To minimize variability in facilitator style, the same three moderators conducted the focus groups. From a class of 126 students, 63 students were allotted Block 1 and 63 were allotted Block 2. In Block 1 three learning experiences were chosen and same for Block 2. Each Block with 21 students again were divided in to 7 students to have three parallel focus groups (Figure). The focus groups were conducted simultaneously at the end of each course at three different venues by the three researchers/moderators. Saturation of data was sought by constituting three parallel focus groups of each module and striving for adequate sample sizes in each group. The average time planned for the focus groups was 50 min.

Qualitative data from each group were collected by three methods: Notes were taken by the facilitator, by a student volunteer from the group, and audio recording was also made and later transcribed. The three sources were filed together for multiple coding.²

RESEARCH INSTRUMENT

1. Structure of Electives: It is designed as per Curriculum Implementation Support Program (CISP) Elective Module: The learner was rotated through two elective blocks of 04 weeks each. These were offered to medical students before the commencement of III MBBS part 2.
2. Feedback of the Elective Module was done through Focus group discussions.
3. Themes for Focus group discussions: The facilitator used the predefined guiding questions to conduct the focus group (Table 1).

SELECTION CRITERIA

Inclusion Criteria:

1. Medical students who have signed informed consent form were included in the study
2. Medical students who have 75% of attendance during both the blocks of electives separately were included in the study

Exclusion Criteria:

1. Medical students who have not signed informed consent form were excluded from the study
2. Medical students who have <75% of attendance during both the blocks of electives separately will be were excluded from the study

DATA ANALYSIS

The study protocol was approved by the Institutional Ethics Committee before the start of the study.

Trustworthiness of data was ensured through multiple coding (Lingard, 2010). At a scheduled meeting, each facilitator reviewed the three sources of information from their focus groups. Common themes from the three documents were independently identified by each facilitator. These were then discussed and a final document was compiled for each class, representing common themes from the three focus groups for the class (Rauf, 2014). 

Few disagreements in the themes were discussed and final consensus was achieved. The first author compiled all the common themes that were identified. With the consensus of all three, perceptions relevant to curricular reform were selected and tabulated along with selected student quotes thus making a structured categorization matrix for common themes from the three parallel groups of one learning experience. In addition, the perceptions common to all the three academic years with regard to the specific categories were plotted as subthemes in another categorization matrix. The discussion was set to encourage naturalistic data that was cross-checked through note taking by three different individuals, specifically the student and moderator to identify latent themes through recordings of their impressions and transcription by co-researcher. The thematic categorization that emerged was reflecting and guiding questions for the focus groups. Member checking was done with students participating in the focus groups (Rauf, 2014).  

Analysis of barriers in implementing focus group discussions was done.

OBSERVATIONS AND RESULTS

We enrolled 126 III Year Phase 1 MBBS Students, of whom all 126 students consented to participate in the study and also participated in focused group discussions were included in our study.

The mean age of the medical students was 21.1±1.7. There were 79 (62.5%) female students and 47 (37.5%) male students.

Elective Module designed by National Medical Commission (NMC) for III-year Phase 1 MBBS students was followed.¹

Our primary objective was to establish the usefulness of focus groups as a strategy to obtain qualitative data for evaluation of new elective module. We aimed to explore students’ perceptions to identify important aspects of the academic program for modifications and improvement. The themes identified from the focus group discussions through the investigators’ analyses included module organization, learning strategies, facilitation, and learning resources.

Each focus group was audio recorded, and the moderator and a volunteer student took additional notes during the session. The audio recordings were transcribed and data obtained from the three sources were analyzed, coded, and categorized independently by three investigators. Both manifest and latent themes were identified, using an inductive approach. Final agreement on themes was reached by comparison of the independently done thematic analysis by the three researchers. Reliability of data was established by comparing responses from the three parallel focus groups of each course.

Trustworthiness of inferences was ensured by multiple coding, audit trail and member checking with focus group participants who reviewed the themes for validity. So, our second objective was also fulfilled.

Tables 2 to 7 gives the details of the parallel focus group discussions. In general, there was consensus among all groups regarding module organization, the learning strategies and need for continuous/daily formative assessments. The students appreciated small groups but some felt that few facilitators should undergo workshops sessions to improve their expertise before the electives.

Following were the barriers in implementing the focus group discussions:

1. Group dynamics within focus groups influence participation and openness. Some participants were hesitant to share their perspectives openly due to hierarchical structures or concerns about judgment from peers or faculty members.
2. Language and communication barriers hindered effective participation and understanding during focus group discussions. Participants from different cultural or linguistic backgrounds struggled to express themselves fully.
3. Faculty members were having busy schedules and were less in number, making it challenging to find suitable times for focus group discussions that accommodate everyone's availability. Time constraints lead to limited participation and affected the depth of discussions.
4. Inexperienced moderators struggled to guide focus group discussions effectively, leading to unstructured conversations or dominant voices overshadowing others. Moderators should be trained in qualitative research methods and facilitation techniques.
5. Organizing focus group discussions requires logistical planning, including booking suitable venues, coordinating schedules, and managing resources.
6. Resistance to implementing focus group discussions was a barrier because of few faculties especially senior.

DISCUSSION

The initiative of this research was to discover the usefulness of focus groups in identifying important issues for curriculum improvement and to explore trustworthiness and representativeness of data during implementation of electives module. Focus groups have been defined as ‘a set of central tendencies with many useful variations that can be matched to a diversity of research purposes’ (Chioncel, 2003).

In our study, our purpose was to identify areas for improvement in the implementation of elective module introduced by NMC for III Year Phase 1 MBBS undergraduate medical students. (Huxman, 2008) compared various methods of collecting student feedback. These included questionnaires, rapid fire questions, and focus groups. It was concluded that the basic difference and richness of one data over the other was due to the questions being open or closed ended. In our study, the change from questionnaires to focus groups for learner’s feedback was in search of this rich qualitative data. However, because focus groups are a relatively uncommon approach for academic program evaluation, the authenticity and trustworthiness of the data was needed to be established.

We noted that the emerging conventionality of views was a result of group interaction and not individual perceptions and opinions. This is probably the reason for the similar feedback received from all the groups. This occurrence of ‘group thinking’ makes the focus group a useful approach to obtain in-depth feedback regarding academic programs (Rauf, 2014).

Our research design was based on having three parallel focus groups for each learning experience which helped us in ensuring the reliability of our data, and was correlating with the study done by Chioncel, 2003.

There was covenant on most themes identified by the three parallel focus groups for each learning experience. This supports the representativeness of the data for program evaluation gathered through focus groups. Our focus groups had students of both genders. Even though there were more females (62.5%) in our study module, there was no issue of dominance observed in our focus groups and the feeling of consensus that developed within each group demonstrated positive group dynamics.

Each guiding query, as it was presented before the group, initiated a discussion and the interaction generated an agreement of opinion, which was then confirmed and accepted. This conformity of agreement was an emergent property of the group context and was not an aggregation of individual participants’ opinions. The descriptive validity of the inferences drawn in this study is supported by the presence of an audit trail, cross validation of data from each of the focus groups for one learning experience through the notes of the moderator, the volunteer student, and the transcription from audio recordings by a second faculty member (Chioncel, 2003).

Iterative thematic analysis, multiple coding, and member check were carried out to preserve the interpretative validity of our inferences (Chioncel, 2003). As with other similar studies, we realize that these results depended upon the skills, insights, critical analysis, and signature style of the researchers (Elo, 2008).

Students’ perceptions regarding the importance given to students’ feedback regarding academic programs has been explored in our study. Focus groups have been used as an integral component of program evaluation to identify issues related to curriculum planning and implementation (Chioncel, 2003). Though laborious and intensive, the focus groups have proved to be a useful tool to be used along with other tools for program evaluation (Stewart, 1996).  Our study, similarly identified issues related to each learning experience as well as common issues across all the learning experiences. The in-depth inquiry inherent to the focus group strategy provided answers and clarifications for concerns identified in previously conducted student questionnaires. Concealed themes identified by the moderators also gave us a feel regarding apprehensions not voiced explicitly by the participants. Concluding the loop through highlighting action taken after the process of evaluation is necessary and we achieved this by circulating the data composed from the focus groups to the course directors and the teams for curricular modifications wherever feasible.

Medical schools are required to continuously assess program effectiveness, especially in light of recent budget cuts and diminishing resources (Vassar, 2010). Given that programs are under increased scrutiny, effective program evaluation has never been more vital. For these reasons, focus group discussions provide a glance into a program evaluation model that is useful in a wide array of contexts within medical education. One of its key benefits is that it is a flexible approach that can be useful in answering a wide variety of programmatic questions. It also actively includes principal stakeholders in the decision making process, increasing the likelihood that results will be used to guide program development and decision making. For these reasons, we encourage those interested in evaluating a particular program to consider the focus group approach.

Strengths of Our Study:

1. Focus groups provided insightful data through the collective opinions and experiences of students, offering a deeper understanding of the topic or issue being discussed.
2. Focus groups also allowed researchers to observe participants' body language, which can provide additional insights into their thoughts and feelings
3. Focus groups were relatively inexpensive compared to other research methods, as they typically involve a small group of participants and minimal equipment
4. Focus groups created emotional connections between students and the faculty, fostering a deeper understanding of the topic and encouraging more open and honest discussions
5. Focus groups generated rich qualitative data, including narratives, stories, and anecdotes, which can provide context and depth to user experiences
6. Because of the homogeneity of our focus groups, which included students from the same level of education, social background, and level of expertise – they belonged to the same class, they were confident in voicing their opinions.
7. However, the richness and usefulness of that data that it gathers makes it a worthwhile tool for information gathering.

Limitations of our study:

1. Focus groups involves a small number of participants, which may not be representative of the entire user population, making it challenging to generalize findings
2. Few students were shy or not comfortable giving information, which posed a challenge for moderators in collecting honest opinions or sparking an interesting conversation. Few students dominated the conversations, drowning out quieter voices from expressing their opinions.
3. Our student feedback of the chosen learning experiences was collected through a single strategy. If we had used other strategies in addition to focus group, the data could be triangulated to strengthen the claim that all important themes were accurately identified. So, focus groups should be used in conjunction with quantitative methods and useful for ‘telling the story’ behind the numbers as in a mixed method design.

CONCLUSION

The data gathered from the focus groups helped to identify students’ preferences and areas for improvement. The observations made provided insight into perceptions that were not explicit. Some perceptions were found to be common among students irrespective of their learning experiences and these preferences can be used across all levels of education and made an integral part of the curriculum. This study gives empirical evidence that focus groups with a random selection of student from a population can be broadly representative of students and the data obtained can be used along with information from other sources for program evaluation and curriculum changes. The richness of data obtained through the use of focus groups for student feedback further validates this approach for program evaluation. Owing to its demands on the administration, it should be used judiciously to identify sensitive issues otherwise not obvious from regular means of feedback or to corroborate other quantitative data

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