The purpose of this paper is to identify essential profession-related competencies, clinical knowledge and skills that medical students should develop in the early stages of their education for future professional practice.
A literature review and workshop resulted in a list of 46 crucial profession-related competencies. The first round of the modified Delphi survey (feedback questionnaire) involved experts who identified 26 items (via a Likert scale). The second round of the modified Delphi survey by faculty members highlighted ten items. Statistical analysis yielded four domains with items clustered as follows: interpersonal competencies (communication and collaboration), cognitive skills (problem solving, critical thinking and reflectivity), work-related skills (planning and time management) and professionalism (integrity, sense of responsibility, respect and empathy).
In conclusion, the results of this study provide insights and implications surrounding the competencies that are essential for assessment and facilitation in the early stages of a medical curriculum. The study also predicts the challenges of facilitating and assessing these competencies, as pointed out in recent literature. In general, outcomes of the study suggest that instead of categorizing the competencies, it is more meaningful to take a holistic and integrated approach in order to conceptualize, facilitate and assess these competencies in context of the complexities of real-life situations.
Ten items were identified as essential profession-related competencies that should be incorporated during the early stages of medical education. Six out of the ten items were agreed upon by all participants of the study: collaboration, communication, problem solving, integrity, responsibility and respect. This list aligns with the existing literature and graduate attributes internationally. Items related to planning and time management, critical thinking and reflectivity were regarded as specifically lacking and important areas of improvement for Arabic students. Divergence on items of empathy and medical ethics were observed among international and local panels, with the main concern, raised by medical faculty, being how to facilitate and assess these items. The competencies identified mandate reforms in the medical school curricula in an attempt to implement essential skills early in medical student’s career.
Du, X., Kassab, S.E., Al-Moslih, A.M., Abu-Hijleh, M.F., Hamdy, H. and Cyprian, F.S. (2019), "Identifying essential competencies for medical students", Journal of Applied Research in Higher Education, Vol. 11 No. 3, pp. 352-366. https://doi.org/10.1108/JARHE-07-2018-0114Download as .RIS
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In medical education, there is a growing interest in the development of professional and personal competencies, in addition to the mastery of medical knowledge and skills. In traditional discipline-based medical curricula, students typically spend three years studying basic sciences and another three to four years on clinical education. In this model, the development of professional competencies is delayed and primarily facilitated during clinical education. With the increase in integrated curricula, such as problem-based learning, team-based learning and organ system-based approaches, students are encouraged to interact with patients (real, simulated and virtual) as early as their first year. Hence, it is recommended that the more general profession-related competencies be emphasized from an early stage. Nevertheless, current efforts surrounding the development of professional competencies mainly take place in the later stages of medical curricula (Lachman and Pawlina, 2006). This study aims to identify the most essential professional competencies that students should develop through the process of a medical program, particularly at an early stage, in preparation for future professional practice.
Although calls for competency-based approaches to the preparation of professionals can be traced back to the 1950s or earlier, this practice has only come to the forefront over the past two decades (Ten Cate and Billett, 2014; Carraccio et al., 2016). Internationally, a wide range of institutions have made efforts to reach agreement on the expected outcomes for medical graduates, including a list of competencies that students should demonstrate at graduation. These efforts include Tomorrow’s Doctors (General Medical Council, 2009), the Tuning Project (Cumming and Ross, 2007) and an outcome project by the Accreditation Council on Graduate Medical Education (Swing, 2007; Lurie et al., 2009). However, there is no consensus on which competencies are important upon entry into a medical school (Albanese et al., 2003; Koenig et al., 2013) nor on which should be incorporated or developed in the early stages of a curriculum.
Definitions of professional competence in medicine vary. In their review study, Epstein and Hundert (2002) summarize the concept as “habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served.” Extensive literature has been published in the English language addressing different aspects of professional competencies in medicine in relation to this definition. Nevertheless, most of the published studies on professional competencies focus on clerkships, interns, residents and physicians, while research on how to facilitate these competencies in undergraduate students and assess them at an early stage remains sparse. Therefore, essential competencies for early stages of medical curricula are the primary focus of the current study. Our research takes an integrated approach that acknowledges the complex and context dependent nature of competency, combining knowledge, attitudes, skills, and personal values and attributes. The development of such competencies involves higher levels of learning activities (Leung, 2002; Frank et al., 2010; Hawkins et al., 2015).
Among the competencies that are reported to be important for an education and subsequent profession in medicine; communication and interpersonal skills are the most frequently addressed. Indeed, several systematic reviews have emphasized the importance of teaching communication skills (Aspegren, 1999) and interpersonal skills (together with communication skills, as part of clinical skills) in medicine (Berkhof et al., 2011; Dornan et al., 2006; Kogan et al., 2009). Such competencies are also termed “soft skills” (Schurink et al., 2006). In addition, a number of cognitive competencies, including problem solving, critical thinking and reflection, among others, are listed as required graduate attributes across countries (Cumming and Ross, 2007; Swing, 2007; Lurie et al., 2009).
Professionalism is another important aspect of medical competency, and is often related to personal characteristics such as humanity and ethics (Veloski et al., 2005; MacKenzie, 2007). Recent research gives increasing attention to developing professionalism in medical education and curricula (Blackall et al., 2007; Du Preez et al., 2007; Klemenc-Ketis and Vrecko, 2014; Ho and Al-Eraky, 2016). Although agreement can be found in the existing literature on a few terms, such as ethics, humanity, empathy, integrity, respect and responsibility, a wide variety of attributes are identified as aspects of professionalism. This is mainly because professionalism is closely linked to context, culture and values. Recent works have begun to conceptualize medical professionalism in the Arabian context (Al-Eraky and Chandratilake, 2012; Abdel-Razig et al., 2016; Ho and Al-Eraky, 2016).
In line with international trends, the majority of medical schools in the Gulf Cooperation Council countries that are based on traditional teacher-centered, hospital-based training approaches are undergoing reforms of undergraduate curricula and encouraging medical students to develop diverse professional proficiencies throughout the curriculum (Ruben, 2000; Ibrahim et al., 2015). However, little agreement has been reached on which professional competencies should be included in medical curricula, particularly in the Middle Eastern context (Mirzazadeh et al., 2014). Thus, there is a need to first identify the profession-related competencies that are essential for medical students before discussing the ways in which students can develop these competencies and how, in turn, can these competencies be assessed. Therefore, this study aims to investigate the following research question:
What are the most important profession-related competencies that medical students should develop during the early stages of their education?
Although professional competence is generally regarded as culturally sensitive (Abdel-Razig et al., 2016) and context dependent (Epstein and Hundert, 2002), a list of frequently addressed skills and values that are related to professional competencies in medicine has been identified in related research across cultures as a first step of this study. In general, these items are subdivided into four domains of relevance: interpersonal competencies, cognitive competencies, work-related skills and professionalism.
Following the literature review, a method inspired by modified Delphi procedures, including two rounds of surveys and face-to-face panel discussions, was employed for data collection. Two panels were consulted: an international panel and a local panel composed of medical faculty from the College of Medicine at Qatar University. The results of the study can, primarily, fill the current gap in the available literature by contributing knowledge about the most important professional competencies for the early stages of modern medical curricula. Next, it can shed light on further work needed on how to develop and integrate curricula that facilitate medical students in gaining these competencies. Finally this study can pave the way to develop processes that can assess these competencies in a least subjective manner. It is also important to note that this study focuses on profession-related competencies, which are supplementary to clinical knowledge and skills. The processes that are eventually developed as a result of this study can be essentially applied to other fields where development of “soft skills” is considered central to the professions.
In Qatar, efforts are being made to transform healthcare from a disease-based approach to an evidence-based approach focusing on integrative care and a preventive approach to disease and patient management (Chouchane et al., 2011). Following this trend, increasing attention has been paid to the development of medical education. For example, a new medical school was established at Qatar University in 2015, in addition to the primary medical college, a branch campus of Weill Cornell Medical College in New York (WCMC-Q). Both medical schools have implemented integrated programs and are engaged in providing open research environments. Nevertheless, current research activities are mainly focused on clinical and health issues with limited attention paid to medical education research thus far.
Participants of the study include: three medical education research experts for a workshop, each with over 30 years of experience developing medical curricula both internationally and in Middle Eastern contexts; an global panel of ten invited international experts for the first modified Delphi survey; and the 18 faculty members who worked as problem-based learning (PBL) tutors at the College of Medicine at Qatar University for the second round of modified Delphi survey. In both Delphi surveys, participants had a variety of national and ethnic backgrounds. All participants had international experience in medical education, encompassing contexts in Middle Eastern, European, North American and African countries.
In order to identify the most important skills related to the medical profession, literature on relevant topics published in English was reviewed. The literature review resulted in a list of competencies, skills and attributes that are regarded as essential for university students to develop in order to prepare for their future professional practice.
Based on the results of the literature review, a one-day workshop was organized with three internationally recognized experts. During the workshop the aims and potential of the study were discussed, and the list of skills and items from the literature review were grouped into four main categories: interpersonal competencies, cognitive competencies, work-related skills and professionalism. A few other items were suggested for inclusion in the list by the workshop participants, including “focus,” “help-seeking” and “sense of humor,” bringing the total number of items to 46. During the workshop, two of the authors of this paper functioned as facilitators and observers.
Subsequently, two surveys were conducted, employing a method inspired by a modified Delphi procedure (Rowe and Wright, 2011). The Delphi method is a well-used approach in the field of medicine and health to gain consensus among a panel of experts (Keeney et al., 2001). Although there is a classic way of employing the Delphi technique, an increasing variation in the use of this method has been reported (Keeney et al., 2001; Okoli and Pawlowski, 2004; Rowe and Wright, 2011). The aim of this study was to identify a list of items on which most experts could agree. In our revised approach, participants were not asked to generate items, but rather to judge the relevance and importance of the items selected in the preceding steps. For convenience, we will henceforward refer to the procedures as Delphi Surveys 1 and 2.
Delphi Survey 1 was conducted with an international panel; the goal was to identify a list of professional competencies essential for medical students to develop in order to prepare for their future professional practice. For the purpose of reaching consensus, selection of participants was based on representativeness of a relevant group instead of random selection (Al-Eraky and Chandratilake, 2012). Criteria for the choice of experts included having an educational background as a doctor, over ten years of work experience in medical education, work experience in clinical settings, research experience in medical education, international working experience in more than two countries, experience in the Middle East and/or leadership experience in medical education programs. The panelists were asked to score the importance of the 46 items listed in Figure 1 using a scale from 1 to 5, from lowest to highest importance. Panelists were invited to write down new items if they considered them highly important, and were welcome to write down the reasons for their scores and suggestions on new items. A total of 10 out of the 14 (71 percent) invited international experts participated in the study during August and September of 2016. All participants fulfilled between four and seven of the above mentioned criteria.
Results from Delphi Survey 1 showed a high level of agreement on a list of items. There were few items added by the Delphi Survey 1 participants. However, panelists unanimously expressed their concern regarding the categorization of the items into the four domains. Several participants commented that some items could be placed in more than one domain and were not independent or mutually exclusive. For example, skills such as communication and collaboration also demand cognition. A few participants commented that the domains were discrete, that the items cut across different levels of skill and competency and that some items were traits instead of skills.
Results from Delphi Survey 1 were reported to the participants by email, and no participant replied to indicate disagreement. A focused group was invited to discuss the results with nine of the ten participants. An initial consensus was reached after around two hours of discussion. Some participants suggested, and all agreed, that the selected items should be sent to the medical faculty members who would serve as tutors in PBL sessions. This was mainly due to the consideration that the tutors would have a considerable amount of time to observe students during the PBL sessions.
Since the overall aim of the study was to identify a list of professional competencies from the perspective of experts with diverse backgrounds rather than to reach a consensus among experts, and because professional competencies can be regarded as highly contextual, Delphi Survey 2 was conducted with a group of tutors who work with students in an Arabic context in September 2016. These were the 18 faculty members (experience ranging from professors to lecturers) who worked as tutors in PBL sessions during the 2016–2017 academic year at the College of Medicine at Qatar University. The study received approval from the Ethical Review IRB office at Qatar University, and all procedures were conducted on a voluntarily basis with full anonymity guaranteed.
Given a list of competencies selected by international experts, the goal now was to achieve a consensus of essential professional competencies in the context of a specific educational institute. The panelists were invited to score the importance of each of the 26 items on a scale of 1 to 5, from lowest to highest importance. No changes were made to the domains in order to align results from Delphi Survey 2 with Survey 1. Afterward, a 3-h long meeting was conducted with all 18 participants to gather feedback and discuss results from Survey 2. During the meeting, the participants were asked to discuss and express their opinions and concerns on the list of the ten most agreed-upon items from Survey 2.
Participants agreed that these items were highly necessary for medical students. Specifically, all participants agreed that six out of the ten listed items are essential to include from the earliest stage of their medical curriculum: “problem solving,” “communication,” “collaboration,” “critical thinking,” “reflecting” and “planning and time management.” Also agreed upon were “integrity,” “respect” and “responsibility,” although a couple of participants expressed concern about how to teach students these attributes of professionalism. Before long other participants convinced them that these values can be facilitated during PBL sessions. However, it took over an hour for the participants to agree that “empathy” was possible to facilitate through medical curricula such as PBL, although it was agreed to be an essential value for the medical profession. Several participants also expressed their confusion regarding the categorization of the items into the four domains with similar reasons to those given by the Survey 1 participants.
Finally, the ten most agreed-upon items from Survey 2 were sent to participants from Survey 1 for their opinions. The results and procedures of the study were also reported to the three international experts who had participated in the initial workshop. No disagreement was received.
Descriptive statistics were computed in order to analyze the responses of the panelists. We computed means and standard deviations for each item of the survey in both rounds. For Delphi Survey 1, we chose the items with a mean score >4.0 (Figure 1), leaving us with a list of 26 items; we believed this was a number sufficient for participants in Survey 2 (Table I) to discuss in order to reach consensus. Although only one panelist responded to the item “critical thinking” with a score of 4, we still included the item for the second survey. For Delphi Survey 2, cumulative scores given to the items by the 18 medical educators were arranged in descending order per item.
For Delphi Survey 2, the scores of the 46 items from Survey 1 were used to narrow down the items to 26. These 26 items, represented in Table I, were re-evaluated by 18 different medical educators, who were asked to choose only ten most important items they believed that medical students should develop during the program. Figure 1 shows results of Delphi Survey 2 with cumulative scores in descending order within each category.
This study is an attempt to identify a list of the most important profession-related competencies students should develop during the early stages of their medical curriculum in order to prepare for their future professional practice. Based on a literature review and a workshop with experts, we proposed a list of 46 frequently addressed skills and values related to professional competencies in medicine, which were subdivided into four domains of relevance. We then conducted two rounds of surveys with modified Delphi procedures, inviting international experts and faculty members at the College of Medicine at Qatar University to score the importance of the items on a scale of 1 to 5 by importance and relevance. Descriptive statistics were computed to analyze the panelists’ responses and rank the items by importance. Out of the 46 items from Delphi Survey 1, 26 had a mean score >4.0; these were used in Survey 2. The ten items with the highest cumulative scores from the participants in Survey 2, deemed to be the most essential competencies for medical students, were: problem solving, collaboration in team, communication, planning and time management, integrity, critical thinking, a sense of responsibility, respect, reflectivity and empathy.
Four domains were identified in the first stage of the study in order to categorize the 46 items. Among the ten items in the final results of the study, two items – communication and collaboration in team – are from the domain of interpersonal competencies, while three items – problem solving, critical thinking and reflectivity – are from the domain of cognitive skills, one item – planning and time management – is from the domain of work-related skills, and four items – integrity, sense of responsibility, respect and empathy – are from the domain of professionalism. However, most of the participants in both Surveys 1 and 2 reported having concerns regarding the categorization of the items into the four domains, which generated unnecessary boundaries and confusion in distinguishing items that could be considered to cross categories. These concerns may potentially add to the obstacles identified in the current debate about competency-based education regarding the struggle of educators to translate conceptual competencies into meaningful changes in curriculum practices (Holmboe, 2015). This gap between participant reaction and literature review also calls for reconsideration of the design for further research and educational activities using a more inclusive approach to account for the complexity of situations in the real world (Leung, 2002; Frank et al., 2010; Hawkins et al., 2015) and for the integration of professional activities and medical practice into curricula (Touchie and Ten Cate, 2015).
The results of this study identified ten essential competencies that should be incorporated into early stages of medical curricula. Among the ten items, six were highly agreed upon by all participants of the study: collaboration, communication, problem solving, integrity, responsibility and respect. These items are also in line with the expected graduate outcomes listed in Tomorrow’s Doctors (General Medical Council, 2009), the Tuning Project (Cumming and Ross, 2007) and an outcome project by the Accreditation Council on Graduate Medical Education (Swing, 2007; Lurie et al., 2009). These items are also highly consistent with international literature and previous studies in Middle Eastern contexts as summarized in this study.
Despite the overall final agreement, a few divergences were observed in this study. The item “planning and time management,” although mostly addressed as an important competency for the medical profession (Epstein and Hundert, 2002; Ariyananda, 2014), was not discussed in terms of its importance within the medical curriculum. In this study, it was emphasized by participants from both surveys (7 participants from Survey 1 and 11 from Survey 2) as one of the major weaknesses of Arabic students, posing a constraint for working efficiently in PBL curricula, echoing results from previous studies (Bin Abdulrahman, 2008; Du et al., 2016).
In comparing the results of Surveys 1 and 2, a few items received differing rates of attention. The concepts of critical thinking and reflectivity received tremendous attention in the literature two decades ago from several countries regarded as Western, but nevertheless remain under-researched in non-Western regions such as Asia (Du et al., 2013; Du, Su and Liu, 2013). In the current study, critical thinking and reflectivity were included in the list of 26 items for Survey 2 panelists due to their scores of 4 and 5 in Survey 1 (Figure 1), respectively. However, only 1 out of the 10 participants in Survey 2 chose creativity and one other chose reflectivity. These two items received little attention in the discussion, but in Survey 2, 8 out of 18 participants voted for critical thinking and 6 for reflectivity. This was further emphasized in the discussion. Based on their daily teaching experiences, participants who were also PBL tutors believed that their students who grew up in Qatari and Arabic contexts demonstrated a great need to improve their abilities to learn independently, think critically and practice reflection. This may be explained by the general recognition of a lack of critical thinking and reflection skills throughout the secondary education system in Qatar (Said, 2016). The identified need for improving critical thinking and reflection is also in line with the results of previous studies conducted with the participation of students from the same college (Du et al., 2016).
In addition, the item of empathy was debated among participants in both surveys. In Survey 1, 7 out of 10 participants rated this item. During the discussion it was debated, and participants agreed to include it as an important value for medical students. In Survey 2, 6 out of the 18 participants voted for it, giving it a ranking of tenth out of ten among the top agreed-upon items. During the discussion it was debated due to concerns from a few participants about whether empathy is something that can be taught, and if so, how to facilitate and assess the teaching of empathy. Although it was finally agreed to list empathy among the essential items to be incorporated into the curriculum, the question remains regarding how to develop well-defined criteria for success around empathy as both a learning process and an outcome, which signals the need for further research in this area.
Another contested area between the two groups of participants was medical ethics. Despite international agreement on its importance, literature on professionalism tends to identify medical ethics as highly culturally sensitive (Abdel-Razig et al., 2016) and context dependent (Epstein and Hundert, 2002). In addition to the focus on medical graduates’ awareness of ethical responsibility suggested in international literature (Epstein and Hundert, 2002; Hilton and Slotnick, 2005; Van Staden et al., 2006; Wagner et al., 2007), adherence to ethical practice was also included in the process of the current study, as suggested by literature on professionalism in Arabic countries (Ruben, 2000; Al-Eraky and Chandratilake, 2012; Abdel-Razig et al., 2016), and emphasized by both the international experts who participated in the initial workshop and Survey 1 participants. Adherence to ethical practice is based on Ihsan, a concept from Islamic principles, referring to the process of translating one’s inner faith into deed and action in order to become a higher being (Abdel-Razig et al., 2016). While participants in the workshop and Survey 1 believed that Ihsan – focusing on the practices of ethical principles – should be emphasized in medical curricula, Survey 2 participants did not particularly focus on this item. Despite their general agreement on the importance of both awareness of ethical responsibility and on the practice of these principles, as expressed in the discussion, only 4 out of 18 participants in Survey 2 voted for these two items, mainly because they found the item to facilitate and assess in their daily practice. Several participants also believed that the awareness of and practices of medical ethics could be developed in later stages of the curriculum and clinical sessions. This result contradicts findings from another study, in which medical students from the same college appreciated and demonstrated their development of ethical thinking through a course focusing on medical humanity (Al Azmeh and Du, 2018). This divergence indicates that further communication is needed among medical educators and administrators regarding when and how to facilitate Ihsan and other needed competencies in the course of medical education.
Defensive organizational cultures are observed universally where high levels of aggressive/defensive and/or passive/defensive cultures are reported to be prevalent (Zeine et al., 2014). Although, not directly probed in this study, the reemerging theme of “respect” in both Delphi survey 1 as well as Delphi survey 2 is indicative of the existence of defensive organizational cultures. As suggested congruously by Zeine et al. (2014), adopting a considerate leadership style may serve to introduce the desired change that is central to student centered approaches such as the PBL and even more relevant in the setting of early clinical exposure.
In conclusion, the results of the study provide insights and implications surrounding the competencies that are essential for assessment and facilitation in the early stages of a medical curriculum. The study also predicts the challenges of facilitating and assessing these competencies, as pointed out in recent literature (Hawkins et al., 2015; Touchie and Ten Cate, 2015). In general, outcomes of the study suggest that instead of categorizing the competencies, it is more meaningful to take a holistic and integrated approach in order to conceptualize, facilitate and assess these competencies in context of the complexities of real-life situations (Leung, 2002; Frank et al., 2010; Hawkins et al., 2015). Further studies are necessary to investigate what types of pedagogical interventions may actually help students improve these professional competencies and what types of assessment should be integrated into the current medical curriculum.
There are a few limitations to this study. First, although this study follows suggestions from previous research in this area on the selection of experts (Keeney et al., 2001; Okoli and Pawlowski, 2004), there may still be potential for bias in the selection that could have affected the results obtained; a larger number of panelists might have strengthened the study and produced more robust results. Second, throughout the study we also found that some medical competencies tend to be described in very general terms, which leaves room for interpretative differences. For example, the item of empathy, despite being highly agreed upon as an essential competency, was constantly questioned in terms of its definition and criteria. Third, the impact of the organizational culture could influence the Delphi process as observed via the difference in feedback from the two surveys that cannot be ruled out subjectivity in a context dependent manner of a newly established PBL curriculum. A multicentered Delphi within the Middle East region would be a better representative. Fourth, with the intention to integrate a consensus from the viewpoints of both international experts and local practitioners, we used different panels for two surveys, which represents a departure from the Delphi tradition and even modified versions of Delphi. Although recent literature (Gnatzy et al., 2011) suggests that the use of modified versions of Delphi that are different from conventional Delphi procedures may produce similar results, the conclusions of the study should be further validated through other methodological approaches.
Results of Delphi survey 2
|No.||Second round of items||Total score|
|3||Reliability and dependability||5|
|6||Resilience and adaptability||3|
|11||Ability to see things in perspective||4|
|14||Planning and time management||11|
|17||Self-management (emotions, mood)||4|
|22||Sense of responsibility||8|
|25||Adherence to ethical practice||4|
Raw data – results of Delphi survey 1
|First round of items||Average||Number of participants||Maximum score||Minimum score||SD|
|Collaboration in team||4.43||7||5||3||0.7868|
|Sense of humor||2.71||7||5||1||1.2536|
|Communication: expressing one’s opinion||3.43||7||4||1||1.1339|
|Communication: giving constructive feedback||3.57||7||5||2||0.9759|
|Communication: receiving feedback positively||4.29||7||5||2||1.1127|
|(Inter) cultural competence||3.71||7||5||3||0.9512|
|Resilience and adaptability||4.57||7||5||4||0.5345|
|Reliability and dependability||4.57||7||5||4||0.5345|
|Richness of ideas||3.43||7||4||2||0.7868|
|Ability to see things in perspective||4.14||7||5||3||0.8997|
|Planning and time management||4.14||7||5||2||1.2150|
|Self-management (emotions, mood)||4.00||7||5||3||0.8165|
|Adherence to ethical practice||4.57||7||5||3||0.7868|
|Advocacy for quality healthcare||3.57||7||5||1||1.3973|
|Capacity for improvement and pursuit of self-perfection||3.29||7||4||1||1.1127|
|Sense of responsibility||4.57||7||5||4||0.5345|
|Education of patients and healthcare providers||3.57||7||5||1||1.6183|
|Ability to engage||3.29||7||5||1||1.2536|
|Ability to recognize health needs of the community||2.86||7||4||1||1.0690|
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The authors acknowledge the contributions of the international panelists and the tutors from the College of Medicine at Qatar University who participated in this study. This research was supported and funded by the College of Medicine, Qatar University.