Educational environment (EE) of any academic institute plays a pivotal role in the academic growth of a medical student and has substantial consequences on the effectiveness of curriculum and on the competency and ultimate success of an individual21. It refers to various physical sets, contexts, and values in which students receive education and perceive their surroundings22. EE is determined by factors such as curriculum, teachers, peers, learning provisions, [1-6] Since medical school is a learning organization, it is important to improve the organizational work environment. Hence, a student’s perception of their learning environment provides a basis for modification in an educational environment in order to improve the learning experiences in regard to teaching goals. 23All private and public sectors of medical colleges in Pakistan offer a five-year MBBS degree program. The first two years focus purely on teaching basic health sciences in light of clinical settings? meanwhile, 3rd, 4th and final years of education [6]. There is a shift in educational trend from traditional, nonintegrated, teacher centered approach to integrated, student-centered approach and this approach is the main pillar on which thinking pattern of future professionals depend. Some of the private medical schools follow an integrated teaching approach, [7].(Problem Based Learning) sessions, SGDs (Small Group Discussions), tutorials, laboratory sessions and interactive lectures. However, most public medical schools still follow traditional (subject based) curricula with each department separately focusing on basic subjects, lectures being the prime focus. There are various diagnostic tools to evaluate an educational environment [10-14]. It is a 50-statement/ item closed questionnaire categorized in 5 sub scales: Students’ perception of learning (12 items) ? Students’ perceptions of teachers (11 items) ? Students’ academic self-perceptions (8 items) ? Students’ perceptions of atmosphere (12 items) and Students’ social self-perceptions (7 items). Each statement is scored using likert scale ranging from “Strongly Agree” (4), “Agree” (3), “Unsure” (2) “Disagree” (1) and “Strongly Disagree” (0). Nine statements are marked in reverse order including items 4, 8, 9, 17, 25, 35, 39, 48 and 50. Higher the score more positive is the learning environment which in turn means better academic achievement, improved quality of life, resilience, positive attitudes towards course, mindfulness, preparedness for practice, less psychological distress, and greater peer support.9 The interpretation of the DREEM total score is 0-50 (very poor), 51-100 (plenty of problems), 101-150 (more positive than negative) and 151-200 (excellent) [15-16]. According to a study in 2019 DREEM scores for medical and dental students are higher than nursing students which have nonintegrated curriculum. Another study conducted in Thailand across 34 teaching hospitals showed educational environment to be more positive than negative with mean score of 131.1 (SD=17.4), and [17-21].

Objectives

• To compare the learning environment in Basic Health Sciences i.e. first and second year MBBS students of private and public medical colleges in Lahore, Pakistan using DREAMSs Questionnaire.
• To highlight impact of both integrated and traditional curriculum on learning

Dental College in 2020.We used a convenient sampling technique.. Ethical approval and IRB approval was obtained from Shalamar Medical and Dental college. The students who were currently enrolled and attending1st and 2nd year classes in private and public medical colleges were included. Private medical colleges with integrated curriculum and public medical colleges with traditional curriculum were also part of it. Students pursuing 3rd, 4th and final year MBBS and those who refused to participate in the study were excluded.Students received the questionnaire in March 2020.  Information was collected from students through self-reported DREEM’s questionnaire via google dox in their class groups to allow honesty with anonymity. They were informed to allow privacy so that they can answer with honesty.. They were asked to provide their actual opinion to make research constructive, and a consent form for their agreement was provided. The questionnaire didn’t have any names to maintain privacy. The questionnaire began with the demographic data (age, gender, residential status level of education, college name and whether their college is following integrated or conventional method of teaching). A total DREEM score between 151 and 200 is considered excellent. A score between 101 and 150 is considered more positive than negative. A score below 151 is considered as “plenty of problems” or very poor. A score of 3.5 or above for individual items indicate presence of the specific aspect of educational environment whereas a less than 3 score requires attention as the students in that case negates the positive influence of educational environment except the negative coded questions. Any value midway between these values indicates that improvement can be made.

Statistical Analysis

Statistical analyses were done using statistical package for social sciences v 20.0. Mean and standard deviations (SD) were calculated for each separate item. Significance level was kept at 0.05

Out of 146 students that participated in the study, 84 (51.21%) belonged to private medical college while 62 (42.46%) belonged to public medical college. The learning environment in both medical colleges’ private and public colleges is perceived as more positive than negative according to DREEM’S questionnaire. (Table 1)

Table 1: Domain score interpretation.

shows DREEMS score interpretation for various subscales. Table 2 shows the mean scores of various subscales and overall mean of the two types of institutes. The overall mean of all five domains were 122.60±29.31 and 111.48±25.16 in private and public medical school respectively (Table 2).

Table 2: Subscale scores in private vs public medical institutes.

While comparing results of each subscale, it was observed that students' perception of atmosphere and students' social self-perception was not of significant difference amongst both types of institutes, while students' perception of learning was significant with p value of 0.029. The scores of students' perception of teachers and student's academic self-perception were also significant (p value = 0.007). The mean score of subscale Student’s perception of learning ( SPL) was in the range of 25 – 36 indicating ‘A more positive approach’ with mean score of 27.84±7.40 in private and 25.19±6.9 in public medical college. All the variables were comparable in both private and public sector medical institutions, except that the students of private medical college think that they are more encouraged to participate in lectures and learning than their counterparts in public medical college. Students of private institute having integrated curriculum found teaching to be more stimulating, student centered, well focused with clear learning objectives than students from public medical college following traditional, non-integrated curriculum.The mean score of  Student’s perception of teaching (SPT) was 27.78±6.07 and 25.17±5.2 in private and public colleges respectively pointing that it is ‘moving in the right direction’. All the statements were comparable in both private and public sector medical institutions except that students from private medical school felt teachers follow more patient centered approach. They also felt that teachers are better at providing feedback to students and teachers come prepared for class compared to their fellows at public institute who felt that their teachers are not too good at providing feedback and need to come more prepared for classes.The score for domain Student’s academic self-perception (SASP) falls in the category ‘Feeling more on the positive side’ with individual scores of 18.22±7.17and 15.16±5.86 respectively.  Students registered with private medical institutions following integrated curriculum felt that they were better prepared for their future professional career and learning about empathy in their profession. They also considered their problem solving skills are better developed and they find the course they are studying, more useful and relevant to their healthcare career compared to students who studied at institution not following integrated curriculum.The mean scores of subscale Student’s perception of atmosphere (SPA) were 30±9.38 and 28.09±9.9 in private and public colleges respectively, indicating ‘a more positive atmosphere’. All statements were comparable in both private and public sector medical institutions apart from the fact that students at private institute felt more comfortable socially in class and considered the environment to be more relaxed during tutorials/ PBLs, however, students enrolled in a public institute were not as comfortable in class socially and environment was not too friendly during tutorials/PBLs. The Student’s social self-perception (SSP) domain mean was 15.90±4.85 for private and 15.45±4.85 for public medical college which is ‘not too bad’. All the statements were comparable in both private and public sector medical institutions except from the fact that private students have better support system in their college for those who get stressed out while an effort needs to be made to provide students from public institute with better stress coping strategies and tools.

SPL: Students’ perception of learning

SPT: Students’ perception of teachers

SASP: Student’s academic self-perception

SPA: Students’ perception of atmosphere

SSSP: Students’ social self-perception

[Table 3]

Table 3: Individual scores of DREEM’S Questionnaire Items.

shows the scores of individual items in different subscales. The items from various subscales were significant in private compared to public institutes especially student centered approach, empathy of teachers for students, comfortable environment of learning, better support system to cope up with stress and better preparation of teachers for sessions. Items italics and asterisk are scored negatively

The study is focused to assess the differences, if any, present in terms of the learning environment between the public and private medical colleges of Lahore with traditional and integrated curriculum respectively. DREEM’S questionnaire was given to 146 first and second year MBBS students of public and private medical institutions. The aim was to identify the strengths and weaknesses of the institutions learning environment which may serve as basis for further improvement of medical education in medical schools of Lahore, Pakistan. This study describes the total DREEM score of 122 in private and 111 in public medical schools in Lahore, which shows more towards positive. However a few students felt disappointed in both sectors depending upon their experience in medical college. The total score is comparable to a previous studies conducted individually in private and public medical colleges of Pakistan which showed score of 117 and 111 respectively [23-24]. Similar study was conducted in Faisalabad medical college, Pakistan (15).  The results are also comparable to the studies conducted in [25-29]. The scores in our study is high compared to international studies done but it does not mean that better teaching facility is present in medical schools of Punjab. It could imply that these students have better perception of their institutions and it meet majority of students’ expectation. Individual domain scores showed that there there is an area of improvement in students’ academic self-perception (SASP) and students self-perception (SSP) in public sector. This might be because learning strategies, problem solving strategies and memorisation skills need improvement by including problem based learning (PBLs) and small group discussions (SGDs) in traditional style teaching methodology. PBL improves the long term learning capabilities [30].  Also, support groups and different curricular and extracurricular activities should be included in annual planner of education year. In private sector on other hand, there is vital need for betterment in area of student self-perception (SSP) which need similar improvement to be made as in public sector. Analysis of sub scales revealed that the highest scores rated in private medical colleges were that “teaching is well focused” and “teachers are well prepared for for their teaching sessions” which proves students satisfaction with the teachers along with their teaching methodology. On the other hand, in the public sector the highest rated questions were “I have good friends in this college” and “the teachers are knowledgeable,” depicting that the public institutions are ensuring the future satisfaction to students and friendly environment.  Students of both public and private institutions think that the lacking points of institutions are that the “course organisers are authoritarian” and “teaching over emphasises factual learning,” which point toward the need of shift from rote learning to clinical based learning along with better student-teacher relationship for delivering the lectures and during medical wards. A study held in India signified differences between high and low academic scorers, showing positive perceptions of high achievers regarding teachers, academic atmosphere and social self-perceptions compared to the under-achievers [31].The most significant statements were “teaching is often stimulating,” “teachers are good at providing feedback to the students,” teachers are well prepared for their teaching sessions,” “I have learnt a lot about empathy in my profession,” “my problem solving skills are being well developed here,” and “there is good support system for the students who get stressed.”

Learning environment in both types of medical schools is perceived as more positive than negative according to DREEM’S questionnaire scale score. Student perceptions were comparable in both private and public sector medical schools in Lahore, Pakistan. But a more significant perception was obtained from private sector medical students regarding students’ perception of learning (SPL), student’s perception of teachers (SPT) and students’ academic self-perception (SASP). However, student’s perception of atmosphere (SPA) and student social self-perception (SSP) were non-significant between both groups

Our study had some limitations. Firstly, Institutional size effect on learning environment has not been evaluated and some evidence from research suggests  favorable learning environment in small-sized medical school as it can increase teacher-student interaction and increase learning opportunities for students. Secondly, one of shortcoming of the DREEM’S questionnaire is that it is a preformed questionnaire and is for international standards which do not fulfil the criteria to include the problems inherent to Pakistani culture and to improve the problems that the study highlighted.

Based on findings of the study public sector medical schools may focus on students’ perception of learning (SPL), students’ perception of teachers (SPT) and students’ academic self-perception (SASP) to improve the learning environment for medical students

We owe thanks to Prof Dr Zahid Bashir Principal SMDC for encouraging medical students for conducting research.

Financial Disclosure: None

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