Qualitative meta-synthesis of feedback sentiments on foundation course for medical undergraduates

INTRODUCTION

The Foundation Course, recommended by the erstwhile Medical Council of India in 2019 and the National Medical Commission at present under Competency-Based Medical Education (CBME), aims to facilitate a smooth transition from high school into the professional medical course for entry-level undergraduate medical students in India.^[1] The course provides a comprehensive introduction to the medical field through various modules, including orientation to healthcare and medical education systems, basic clinical and communication skills, enhancement of language and computer skills, various learning strategies, and peer and faculty interactions. The foundation course for medical undergraduates in India is expected to play a pivotal role in shaping the initial phase of their medical education, providing essential skills and knowledge that form the bedrock of their future training and practice. Such a Foundation Course has been previously recommended at the entry level for medical undergraduates before the introduction of CBME.^[2] Analyzing feedback on this course is crucial for understanding how it is received and identifying areas for improvement.

In quantitative terms, the course has received a positive response.^[3,4] However, as it is a new course, incremental improvements are essential to enhance its effectiveness. Students’ qualitative feedback plays a crucial role in identifying areas that require refinement and adjustment, ensuring that the Foundation Course continues to meet the needs and expectations of medical undergraduates. Qualitative Meta-Synthesis serves as a robust method for synthesizing qualitative data from multiple studies, offering a comprehensive overview of the sentiments expressed by students and faculty.^[5,6] It is an interpretative integration of qualitative findings from similar studies in a related area to get a fresh and collective understanding.^[7] Unlike individual qualitative studies, qualitative meta-synthesis aggregates diverse perspectives from different contexts, offering a broader understanding of patterns and contradictions. This overall understanding has the potential to facilitate informed decision-making at the policy level and enhance the overall quality of medical education.^[8] Hence, the objective was to synthesize the sentiments from feedback on the Foundation Course recommended by the medical regulator of India.

MATERIAL AND METHODS

Selection of primary studies and their appraisal

In initial mapping, we obtained a total of 69 articles. After removing four duplicates, we screened the titles and abstracts of the remaining 65 articles. We excluded 50 articles from the initial screening as they were not relevant to the study purpose. We then assessed the full text of 15 articles and excluded 11 primary studies based on the following inclusion criteria: Original qualitative and mixed methods research related to the “Foundation Course” published before November 2024. Flow of article selection and reasons for exclusion followed the PRISMA flow diagram are shown in Figure 1. We then assessed the full text of all four selected articles^[14-17] to identify the parts of primary studies that relate to the purpose of the study. As we conducted a realist type of meta-synthesis with a practice-focused approach, the number of studies and saturation were not primary concerns.^[18,19] We used the Critical Appraisal Skills Program (CASP) checklist questions to assess methodological quality.^[20] The included studies met all the CASP criteria, except for limited reporting on reflexivity. The background details of the selected studies are given in Table 1.

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Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analysis flowchart to demonstrate the flow of search resulting in the inclusion of related articles.

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Table 1: Details of articles selected for meta-synthesis.

S. No.	Author	Year of publication	Journal	Title	Region	Target group	Study design	Objective/s
1	Pandey et al.[14]	2021	Medical Journal Armed Forces India	One-month long foundation course for newly joined Indian medical undergraduates: Faculty and students’ perspective	Karnataka	Students Teachers	Mixed Methods	To showcase experience of implementing a 1-month long FC prescribed by NMC. It also intends to evaluate the student and faculty perspectives on the effectiveness of the course.
2	Velusami et al.[15]	2020	Journal of Advances in Medical Education and Professionalism	Evaluation of 1-month foundation course for the 1st-year undergraduate students at a Medical College in Puducherry, India	Pondicherry	Students Teachers	Mixed Methods	To evaluate the first foundation course using the students and faculty members’ point of view
3	Sobti et al.[16]	2020	J Family Med Prim Care	Assessment of newly introduced foundation course for medical undergraduates: students’ versus faculty’s perspective	Jammu and Kashmir	Student and Faculty	Mixed Methods	To seek the opinion of the students and faculty regarding relevance of the topics included in the course to enable revisions to be made in designing the course for the subsequent sessions, to make it more effective and student-oriented.
4	Bhatnagar and Oberoi[17]	2022	Industrial Psychiatry Journal	Students’ perceptions on newly designed foundation course at MBBS entry level: A mixedmethod study	Port Blair	Students Teachers	Mixed Methods	To describe the process and evaluate the impact of the course.

FC: Foundation course, NMC: National Medical Commission

RESULTS

Except for one, the remaining three studies were conducted in the southern part of India. All four studies utilized Mixed Methods design and gathered feedback from two stakeholders, i.e., students and faculty.

The qualitative text corpus had 1813 total words. The software detected 62 occurrences of positive words. The context of each word was examined by referring to the full sentence around it. Forty-three positive words with full sentences that offered a clear description of the context were included in the making of meta-categories. The context of positive keywords is organized under five meta-categories: (1) Icebreaking; (2) Teaching-learning approach; (3) Attitude and communication sessions; (4) Language and computer skills; and (5) Sessions on sports and extracurricular activities. Specific details of meta-categories are given in Table 2. Words and statements in Italics are quotes from the primary studies.

In addition, the software identified 28 occurrences of negative words. Each word’s context was analyzed by reviewing the entire sentence it appeared in. Out of these, 24 sentences with negative words providing a clear context were chosen for meta-categorization. The context of negative keywords is classified into four meta-categories: (1) Managing large groups with a tight course schedule; (2) Communication in a new language; (3) Perceptions of students with early exposure to the healthcare system; and (4) Suggestions for improvement. Specific details of meta-categories are given in Table 3.

DISCUSSION

Overall, the findings suggest a largely positive reception of the Foundation Course, alongside recurring concerns about large group management, a tight schedule, language-related difficulties, and areas for improvement.

As the Foundation Course is a relatively new educational intervention, most of the studies have focused on Kirkpatrick level 1, which involves assessing the initial reactions of the learners.^[11] Notably, in peer validation, students felt that the large group was efficiently managed through more interactive sessions. Managing learners’ perceptions is crucial as it significantly influences their academic engagement and success. Positive perceptions were found to enhance students’ enthusiasm for learning and contribute to a more effective educational experience.^[28] Effective change management is essential for addressing negative feedback, as it helps educational institutions navigate transitions smoothly and foster a culture of continuous improvement. The Foundation Course aligns with the National Education Policy 2020, which emphasizes holistic education to ensure the overall development of students.^[29] The Foundation Course offers an excellent opportunity to initiate personal development, trust, empathy, and cooperation among students. It has the potential to develop inner attributes such as being present, intentional, and non-reactive in complex situations, critical thinking, and feeling connected to others. Through collaboration, students can make progress on shared concerns and act on issues with persistence. These attributes are expected to produce resilient health professionals with the inner strength to address complex challenges and find sustainable solutions in uncertain situations.^[30]

Whereas the Foundation Course has several strengths, it also faces challenges such as managing large student numbers, a tight schedule, and content overload. These issues can be addressed through regular feedback and ongoing course revisions. Incremental changes will help align the course more closely with student expectations and overall objectives, supported by faculty training and course restructuring based on the feedback received. Lewin’s Change Management Model helps in this process by classifying feedback into driving forces (support for change) and restraining forces (opposition to change), thereby enabling targeted strategies to strengthen support and reduce resistance to achieve the desired outcomes of the Foundation Course.^[13]

By using a combination of evaluation frameworks and integrating sentiment analysis with KWIC analysis and thematic organization, this approach provided a holistic view of the feedback, capturing both the sentiments and the context in which they were expressed. The validation and peer review process ensured that the findings were accurate and reliable, reducing subjective interpretation and errors. The thematic organization of sentiments allowed for the identification of key themes and issues, enabling stakeholders to address specific concerns and improve overall user satisfaction. Software-assisted analysis aided in accurate categorization by consistently applying predefined rules, minimizing human error. For example, when processing large amounts of feedback data or reflective essays, the automation ensured that no data are omitted, and every relevant piece of information is captured.^[31,32] This consistency and thoroughness led to reliable and unbiased results, making it a novel approach for analyzing extensive text data in educational research.

Given the type of data, we were unable to synthesize long-term course outcomes in terms of skills acquisition, behavior change, and the pathways taken to achieve them. Future studies should focus on measuring long-term outcomes within established frameworks to achieve these goals. KWIC analysis provided context for keywords, but it might not fully capture the nuances of sentiments, especially in complex or ambiguous statements. Out of the four selected studies, three were from the southern part of India, limiting geographical representation in findings.

CONCLUSION

In conclusion, this study captured mixed sentiments and their context, offering a balanced understanding of the Foundation Course. The course appears to be a well-received educational intervention in the undergraduate medical curriculum. Ongoing evaluation and continuous improvement may further enhance the course and help achieve its learning goals. In addition, automated web-based software may support rapid and accurate analysis of large qualitative text datasets.