Faculty members’ perception towards changes in Medical Education in Saudi Arabia

Introduction and aim: Medical Education journey in Saudi Arabia started from about 50 years ago, however, it witnessed a lot of changes and rapid development in the last 10 years especially with the increase the number of medical colleges. Medical Education in Saudi Arabia seems to follow the same international pattern regarding the change process. There is a great need for a rigorous approach for evaluating the effectiveness of this changes and the process of its management. The aim of this study is to evaluate medical education change in Saudi Arabia from Faculty Staff Members’ point of view. Method: The research was conducted through a cross-sectional study using a survey and grounded theory, as a mixed methods strategy. Results: The challenge that has the highest perception was the shortage of well-trained Faculty Staff Member. The strategies for implementing change are categorized into three categories: Curriculum reform, faculty development and improving learning environment. Conclusion: Change could be implemented through curriculum reform with the help of qualified Faculty staff members in presence of an enabling learning environment and supportive organizational measures. In Saudi Arabia, a variety of strategies was used for implementing change in medical education, without any preference to specific one.

The second phase of medical education in Saudi Arabia witnessed the establishment of many new universities and colleges of medicine. There was strong support from the Ministry of Higher Education for medical education in particular to help to close the gap due to the shortage in the number of health care providers in the Kingdom especially the physicians. By the year 2008, there were 21 medical colleges in Saudi Arabia; three of them private colleges. In the year 2011, the number of medical schools in Saudi Arabia became 31 schools, both governmental and private, which means 10 new schools were established in only three years. (Bin Abdulrahman, 2011).
This phase also witnessed the establishment of the National Commission for Assessment and Accreditation (NCAAA) which is responsible for accrediting all higher education in institutions and programs in Saudi Arabia. There was a paradigm shift of medical education program toward innovation and a more student centred approach. A variety of curricula were adopted in different colleges with the common features of adopting: more integrated curriculum, problem based learning, and community based learning. The difference between colleges was mainly in the extent and depth of each approach. Some colleges adopt a pure problem based and community oriented curriculum and others adopt a hybrid integrated community based or problem based curriculum. On the other hand some schools remained on its traditional curriculum with attempts to introduce new teaching strategies to improve the learning environment (Telmesani, 2011).
One of the milestones of the second phase of medical education was the development of Saudi Med which is a national competence framework of seven domains that could guide curriculum development and ensure equivalent standards among medical colleges in Saudi Arabia. This framework was developed by the collaboration between The Saudi Deans Committee and the Saudi Society for Medical Education, both have an active role in the field of medical education in Saudi Arabia .
Finally the establishments of many medical education departments in colleges of medicine reflected the high interest Hassanien M MedEdPublish https://doi.org/10.15694/mep.2018.0000023.1 Page | 3 of developing and monitoring medical education in Saudi Arabia. Also, this interest was reflected in the number of published medical education researches originally come from Saudi Arabia and for this reason Medical Teacher journal with the collaboration with Dr. Hamza Alkholi Chair for Developing Medical Education in Saudi Arabia published the Saudi supplement of this prestigious journal (Bin Abdulrahman, 2012).
In conclusion, the Medical Education journey in Saudi Arabia started from about 50 years ago, however, it witnessed a lot of changes and rapid development in the last 10 years especially with the increase the number of medical colleges, about 25 medical schools were established in the last 10 years with an average of more than two colleges per year. Medical Education in Saudi Arabia seems to follow the same international pattern with main differences in the rate of growth and the rate of change; both are so rapid in comparison with the international trends. This added more pressure on medical colleges especially in the area related to quality of educational programs and quality of outcomes. There is a great need for a rigorous approach for evaluating the effectiveness of this change and even the process of its management. There is no published data about evaluating the effectiveness of the change in medical education in Saudi Arabia which could be explained by the short period of this change.
The aim of this study is to evaluate change in medical education in Saudi Arabia from Faculty members' point of view, with an emphasis on the challenges and strategies related to its implementation. The research methodology framework proposed by Saunders 2009 was followed for study design. The research was conducted through a cross-sectional study using a survey and grounded theory, as a mixed methods strategy. The study's approach is a combined deductive and inductive, based on both positivism and interpretivism philosophies. Fig. 2 Philosophies: This study, has followed a combined method (triangulation) approach as survey and interview 1.
are chosen to verify various aspects of research study. Using survey is supported by "positivist" to examine underlying assumptions related to the challenges facing medical education in Saudi Arabia and established by literature review. On the other hand, "interpretivist" approach is followed when analysing and interpreting data coming from the interviews. Approaches: Also a combined approach was followed in this study, both Deductive and Inductive. Deductive 2.
approach is the approach followed on evaluating the challenges facing medical education in Saudi Arabia, while both deductive and inductive approach were followed for evaluating the strategies followed for change implantation. Strategies: Among different research strategies, this study was conducted using a survey questionnaire and 3.
semi-structured interview as a research strategy. Choices, Quantative vs Qualtative study: A mixed method was used in this study, combined quantitative 4. and qualitative to eliminate the limitation of each method and to get more understanding of the topics of the study. Data collection: Quantative data was collected using online questionnaire and qualitative data was a.
collected from semi-structured interview. Sample selection: The participants of this study (74 in the questionnaire and six in the interview) are b. experts in medical education from different Medical and Dentistry colleges in Saudi Arabia. As there is no available data base for all those experts, it was difficult to accurately calculate the sample size for the study. Participants were mainly members of "Nice Group" which is a Whatsapp group that has 187 medical educationists from different areas of Saudi Arabia. Some participants were purposively selected by the author, as they are well known as a medical education experts in Saudi Arabia.

I -Quantitative data collection and analysis
A questionnaire was designed to collect quantitative data from faculty members of medical colleges in Saudi Arabia. A questionnaire was designed to collect quantitative data from faculty members of medical colleges in Saudi Arabia. The questionnaire has three components: Participants' demographic data, including their university affiliation, gender, academic rank, qualifications and a.
duration of career. Twenty Questions about the challenges facing medical education in Saudi Arabia. For purpose of comparing b. and discussing the results, those questions were categorized into five categories. Twenty Questions related to strategies for implementing changes in Medical Education in Saudi Arabia. c.
Sections B and C featured a Likert rating scale from 1 to 5. The questionnaire was conducted online using Google Docs.(https://goo.gl/forms/PzJdDU7WryBB6zYw2) Data was collected in an Excel sheet and analysed for descriptive statistics. For purpose of comparing and discussing the results, both section B and C questions were categorized into five and three categories respectively.
The questionnaire was validated by giving it to three experts in Medical Education to check it for: coverage of the topic, avoidance of ambiguity and clear language. Also, the questionnaire was piloted by giving it to ten Faculty members to check also for any ambiguity that needed correcting and clarity of language. According to the validation process, two questions were omitted as being considered of no significance to the study, also rearrangement of some questions was done to keep participants' attention.

II -Qualitative data collection and analysis
A semi-structured interview was used to collect qualitative data from six experts in medical education and the grounded theory approach was followed to analyse the data obtained from the transcripts of each interview. The interview was designed to have two main themes: Different experience with medical education change in Saudi Arabia and Different strategies for change management in medical education. Qualtative data analysis was done using grounded theory with the aim to build a conceptual framework for management change in medical education in Saudi Arabia. Application of the grounded theory in the current study: The Grounded theory procedures: Grounded theory was applied in three levels of analysis (Strauss and Corbin 1990): Data presentation without abstraction or interpretation, just as told by participants in the interview. 1.
A descriptive narrative was created using interview transcript, field notes and my own interpretations.

2.
A theory or conceptual framework was built using a high level abstraction and interpretation. 3.

Measures taken to enhance the research' quality:
Ethical consideration: Ethical guideline of York St John University was followed by completing Research 1.
Ethical Considerations Screening Checklist . Reliability and Validity: Some measures were taken to improve both reliability and validity of this study.

2.
Reliability: four measures were taken to ensure reliability of current study, they are: Research a.
methodology was fully explained, research questions were clearly stated, Researcher role was fully described in later section and finally an audit trail was kept. The audit trail contains: Excel sheet for the data of online questionnaires, interview data, quantitative data statistics and Grounded theory memos and coding sheets. Validity: The following techniques were followed to increase the validity of the current study which is b.
mainly through: Data source triangulation: It has three types, Personal, space and time. Data was collected from diverse experts of medical education from different medical and dental schools in Saudi Arabia, this is to ensure both personal and space triangulation. The link of online questionnaire was sent twice with one month period apart to ensure time triangulation. These measures which enhance data source triangulation gave a good chance to increase the accuracy of data and decrease the chance of getting random errors from premature inference. Also using both qualitative and quantative data collection methods were one of the measures of data source triangulation. Table 1: illustrated the demographic data of study's participants, 55.4% were male and 44.6 were female faculty members. The majority of them (85.1 %) are from different colleges of medicine in Kingdom of Saudi Arabia and (14.9%) from different dentistry colleges. More than two thirds of them are holding PhD and have more than ten years of experience in medical education.  Table 2 and 3 illustrated Faculty staff members' perception towards the challenges facing medical education in Saudi Arabia. Table 2 illustrated the descriptive data of Faculty's perception for the twenty statements represented various challenges facing medical education. The data was represented in terms of mean and standards deviation. For the purpose of comparing data and discussing various challenges, the twenty statements were assembled into five themes that represent the main challenges. The descriptive data of the main themes were illustrated in Table 3, combined with the results of statistical comparison of different means. The challenges related to shortage of qualified Faculty members shows the highest mean (4.4 ± 0.1) and that related to the advancement in information technology shows the lowest mean (3.6 ± 0.1). On comparing all themes using both ANOVA and Holm-Sidak method, there were significant differences between means.  Table 4 and 5 illustrated Faculty staff members' perception towards the Suggested strategies for implanting change in medical education Table 4 illustrated the descriptive data of Faculty's perception for the twenty strategies represented various suggested strategies for implementing change in medical education. The data was represented in term of mean and standards deviation. For the purpose of comparing data and discussing various strategies, the twenty statements were assembled into three themes that represent the main categories of change strategies. The descriptive data of the main themes were illustrated in Table 3, combined with the results of statistical comparison of different means. Both categories of strategies related to curriculum reform and Faculty development have the same mean (4.2) and that improving learning environment has (4.1) with no significant differences on comparing all categories.   Table 6 illustrates the use of grounded theory for analyzing qualitative data of the current study. Codes were elected from interviews' transcripts and all were listed in the right column of Table 6. Codes are arranged and aligned in different subcategories in the middle column, Finally according to subcategories, four core categories were emerged which represent measures or strategies used in implementing change in different medical schools in Saudi Arabia and also some obstacles which facing change process. The three categories which represent change strategies are Organizational measure, Building capacity and Curriculum reform.

Discussion
This cross sectional study was conducted to evaluate medical education change in Saudi Arabia from Faculty members' point of view. Data collection method was mixed using questionnaire and semi-structured interview.
Grounded theory was used to analyze interview qualitative data. Faculty staff members from medical and dentistry schools participated in the study; they have medical education background and almost all of them had a PhD from different medical and dentistry specialties. An emphasis was done on the challenges facing medical education in Saudi Arabia and the possible strategies for change.
According to the results of this study, challenges are categorized into five groups: Challenges related to stakeholders' needs, Challenges related to Medical Education Curricula and programs, Challenges related to shortage of qualified Faculty members, and Challenges related to the advancement in Information Technology. All the means of rating of these challenges were above 3.5 in a scale out of five, which mean that all of them should be considered and need to be dealt with during the change process. The highest rate was for the challenges related to shortage of qualified Faculty members.
Telmesani, 2011 mentioned that, one of the challenge that faces medical education in Saudi Arabia is to supply the recently developed medical schools with enough varieties of competent staff. The Gulf Cooperative Council countries Committee of Deans of Medical schools suggested that the ideal staff-to-student ratio is 1:7. Unfortunately, a considerable number of the already working colleges are confronted with lack in the number of Faculty members, even with a staff-to-student ratio far away from what is ideal. The problem is complicated by an unsatisfactory Faculty compensation scale as matched up with other international universities and private health care centres, a similar circumstance to Malaysia (Lim, 2008) Many authors wrote about the shift in public attitude as secondary stakeholders, (MacLellan, 1998, Jadad, 1999, Zoeller, 1999, Bloom, 1999, Larkin, 1999, Dennis, 2014, Kitching, 2015and Shi, 2016. They claimed that the challenges due to the shift in the public attitude are mainly due to two main reasons. First, the great expansion, easy accessibility and availability of medical information. These has supplied interested clients/ patients the access to study and search for conditions, symptoms, management and even ask for another opinion. The second reason is mainly based on the new era of accountability and assessment and which has a tremendous effects on all segments of community, including health care services. This is a promising growth, especially if it is associated with enhanced data flow to guide decision making at all levels, involving that of clients /patient.
Regarding the challenges that emerged due to the need for curriculum reform, in the early twentieth first century; Al-Gindan, 2000, mentioned that, there is a need for reform of the current medical curricula in Saudi Arabia. This reform is mainly in the form of eliminating non-relevant information, modification of basic sciences courses to be more clinically relevant, early introduction of clinical experience, introduction of community based medical education besides the traditional hospital based one, promote critical thinking and encourage lifelong and finally effective use of available resources. Faculty members who participated in this study also valued the need for curriculum reform with the emphasis on: learners' need to demonstrate competencies, the shift from content basedto outcomes-based curricula, making the medical education curriculum more student-centred than teacher-centred and making the medical education curriculum more integrated both horizontally and vertically and problem based.
Regarding strategies measures for change implementation in medical education in Saudi Arabia, according to the results of current study, they include: Curriculum reform, Faculty development, improving the learning environment. These strategies should be done combined with organizational measures which facilitate the change process and overcome obstacles against change.
Enarson & Burg, 1992 highlighted the need for training students on critical thinking, problem-solving and reforming curriculum with the emphasis on more integration between basic and clinical sciences. Introduction of new courses such as patient safety module led to the improvement in students' concepts and kills in this area and even they could critically analyze the errors due to system dysfunction and shifted their sense of social responsibility. After training, students increasingly attributed errors to system dysfunction and reported more selfconfidence in speaking up about colleagues' errors. However, due to the hierarchical culture, students still described difficulties communicating with senior doctors (Roh, 2015).
Different areas for Faculty staff members' development were acknowledged by the participants of the current study. These areas include: Curriculum design and evaluation, Student Assessment, course organization, Facilitation skills and role model skills. Actually, these areas are based on the view reported by Harden, 2000 he mentioned twelve roles for medical teacher in modern medical education. These roles are categorized in six areas: Role model, Information provider, Examiner, Facilitator, Planner and resource developer. Faculty development is essential to help faculty staff member to fulfill these new roles which is far from the conventional role as information giver.
Last but not least the strategy for changing medical education in Saudi Arabia as acknowledged by participants is improving the learning environment. The strategies for improving the learning environment include: Effective use of available resources with the emphasis on integrating technology in teaching, Providing easy and comfortable access to various information communication technology tools and establishing learning centres which equipped with all required technology. Similar to these strategies, Guze, 2015 emphasized the importance of using technology as an infrastructure to enhance learning environment and as a basis to address many of challenges facing medical education. Guze, 2015 highlighted some of the technologies which could aid and support learning environment, such as: computer assisted learning, Personal digital assistants (PDAs) using mobile devices, Digital games and the so called "serious gaming", Simulation like virtual reality and Wearable Technologies.
Finally, some Faculty staff members participating in this study described their experience in changing medical education in Saudi Arabia; one can conclude their description as different medical schools in Saudi Arabia use a variety of strategies for implementing change in medical education. These strategies include curriculum reform and building capacity to cope with challenges, for enhancing change process, there are certain measures at the level of organization should be followed to facilitate the change process. The measures include: changing organizational structure, Leadership and management support for change, proper planning for change and starting the change process as a part of either national or international academic accreditation like what happened in School of Medicine, Stony Brook University (SBU SOM), they utilized a Liaison Committee on Medical Education (LCME) site visit to design a change management process. (Chandran, 2013)

Limitations of the study
There are some limitations in this study; the main limitation is the number and diversity of participants, which is due to time constraints and the lack of a full data base of medical educationists in Saudi Arabia, so the author used a judgmental method for sampling. Also one of the limitations of the study is the lack of full data for comparing change strategies in different medical schools in Saudi Arabia.

Recommendations for further research
More and detailed studies are required for evaluating change in medical education in Saudi Arabia with comparison of different strategies used in different colleges with measuring the effectiveness of each of them. The evaluation should not be limited only to Faculty staff members' and students' opinion, but also to cover its tangible effects on Medical education outcomes due to curriculum reform and using new teaching strategies. A cross case pattern comparison study is recommended as national project to compare the effectiveness of different strategies on the change process.

Conclusions and recommendations
Change could be implemented through curriculum reform with the help of qualified Faculty staff members in presence of an enabling learning environment and supportive organizational measures. Almost all Medical Schools in Saudi Arabia utilized a variety of strategies for implementing change in Medical Education. These strategies included curriculum reform and building capacity to cope with challenges. Building capacity was mediated through Faculty development, improving learning environment with the emphasis on using technology, benefit from local and international experiences and changing culture mainly through accreditation and establishing quality unit and medical education department