he Singapore polyclinic has evolved to efficiently provide a comprehensive range of services to screen, prevent, and manage the range of medical conditions of epidemiological importance to the Singapore population. These services range from the immunization and screening of children, to the care of elderly patients with multiple chronic medical conditions (medical conditions that require long-term medication and follow up). In this article, we write about a qualitative study to evaluate the reactions of medical students to a mobile app employed to learn about healthcare services within the polyclinic.

Polyclinic Services

In the 2010 Primary Care Survey1 conducted by the Ministry of Health, of the close to 12,000 patients who consulted at the then 18 polyclinics in one day (at present, there are 19 polyclinics), 40% of the consultations were primarily for chronic medical conditions. Typically an individual patient with chronic disease will be seen by a team of healthcare professionals at various service points within the polyclinic. For instance, a patient with diabetes mellitus gets his blood taken by the laboratory technician, he may then have his eyes checked at the retinal photography station, get his feet checked for numbness at the nursing station, have a medical consult with the family physician, and then collect the medication that is dispensed by the pharmacist. In addition, he may have an appointment at the dietitian's office with his wife, and he may need to consult the nursing-trained care manager to learn about home glucose monitoring.

Medical School

At the Yong Loo Lin School of Medicine, National University of Singapore (NUSmed), students are posted to designated polyclinics in groups of 7–8 as a component of the family medicine posting in the third-year of the curriculum. With the burden of chronic disease projected to increase in tandem with the rapidly ageing population, medical students need to understand the range of healthcare services available for the comprehensive care of patients within the polyclinic setting.

Mobile Application

In order to structure learning about the range of healthcare services at the polyclinic, we leveraged on the high (87% according to Nielsen²) mobile phone ownership in Singapore, and hypothesized that the use of a mobile app to learn about the roles and services at polyclinic service-points would be well received by Generation Y learners. We felt that the mobile app would be an ideal platform for self-directed learning by guiding students as they made their way around the busy polyclinic from point to point, and providing just-in-time educational interactions at each point-of-care.

We named the app "IPTeam Polyclinic": "IPteam" in order to recognize the inter-professional nature of the team of healthcare providers at the polyclinic, and "polyclinic" to situate the context in which the learning app was to be used.

In order to organize the content in the app, fifteen healthcare service points common to both Singhealth and National Healthcare Group polyclinics were categorized into one of three content segments: Nursing, Allied Health, and Diagnostics (Table 1, Fig 1).

Educational interactions were designed for each point-of-care. The 'Before' activity introduced the service and learning objectives. An 'Ask' section provided questions for encouraging discussion with the designated healthcare professional. On average students stayed at each service point for 30–45 minutes. Students are quizzed with multiple-choice questions 'After' leaving each service point. Figure 2 represents an example of a quiz in the app.

Qualitative Study

An exploratory qualitative study using focus group interviews was conducted in Aug 2013 to evaluate the reactions of third-year medical students toward using the IPTeam mobile application at the Polyclinic. The study research questions were:

1. What were the reactions of third-year medical students towards the IPTeam app used for learning about the healthcare services at the polyclinic?
2. What factors encouraged students to use the mobile application?
3. What challenges did students encounter when using the mobile application? Purposive sampling was used with students who used the IPTeam app during their rotation to the polyclinic. Students who were absent, or who did not use the mobile app were excluded from the sample. In this study, there were three focus group discussions and a total of 22 students were interviewed. This was adequate (two to five focus groups recommended) for the emergence of categories across and between groups, and for data saturation to be reached.

Table 2 presents the demographic data of the participants.

The study had 22 participants, with an equal number of males (N=11) and females (N=11). The average age of participants was 21-years-old, with age range between 21- to 22-years-old. All participants used their smartphones for at least six months. All the participants had been at the polyclinic for a minimum of one day to a maximum of eight days. The majority of participants used the application more than twice a day for their learning and most of the participants used the mobile application without prior training.

Prior ethical approval was obtained from the university Institutional Review Board (IRB). Semi¡ªstructured open-ended questions were used for the interviews. The interview questions and prompts were developed based on literature reviews, and the modified Acceptance Model. An integrated circuit recorder was used to record discussions for data accuracy, and data collection was continued until data saturation was reached. Table 3 presents the examples of questions and prompts used to guide the interviews.

Data Analysis

Descriptive statistics was used to analyze the participants' demographic data. Interview records were transcribed verbatim, and the content analysis method was used to analyze the data. This method involved coding and developing categories. After analysis was completed for each piece of data, the results were discussed, categories created and overlapping categories clustered into larger categories. This was done to ensure the holistic capture of the perceptions of all three members of the research team.The criteria for credibility, dependability, confirmability, and transferability were used to evaluate the rigor of the study.

Four Coding Categories

After rigorous data analysis and review by the research team, four main coding categories were identified: (1) the enrichment of learning, (2) motivating factors, (3) barriers, and (4) unintended consequences. Quotations are presented in Table 4.

Discussion

The app was well received as a learning tool as the team had hypothesized.

In our focus group discussion, user-friendliness motivated learners to use the app. Learners appreciated the introduction at each service point, the 'Ask' function that facilitated engagement, and the quiz questions after each educational interaction. Suggestions to further improve the app include: minimizing the discrepancy between app content and real world experience, providing clear "help" and "error" messages, and providing 'exit', 'undo' and 'redo' functions. Learners found the login password unnecessary, and noted minor bugs in the application software. The advantages of using Mobile apps to understand the pointsof- service at the polyclinic include: Learners could self- or groupnavigate between different points-of-care, to receive just-in-time learning through app-encouraged interactions (Before, Ask, After) with the healthcare staff at each point of service, without the use of additional manpower.

Distracting and Disrespectful

An interesting outcome of this study was the finding that students thought that use of the app could be both distracting and disrespectful.

So although this qualitative study shows that learning about the healthcare service points at the polyclinic using the IPTeam app is feasible and has high user acceptability among medical students, educators and users of m-learning in their learning activities need to be mindful of mobile phone etiquette in the planning of their programs. The concerns quite rightly raised by the students underline the need to find the right balance in the use of technology-enablers in teaching without detracting from what is most central in medical education: the relational aspect of physician training.

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