Exploring medical educators’ perspectives on teaching effectiveness and student learning

Abstract

Background

Medical education in resource-constrained settings such as Pakistan faces significant challenges, including large class sizes, limited resources, and reliance on traditional teacher-centered pedagogies. These factors hinder effective learning and fail to equip students with the critical thinking and practical skills essential for modern medical practice. Educators play a fundamental role in shaping student experiences but often struggle to adopt student-centred methodologies due to insufficient training, resource limitations, and institutional constraints. This study aimed to explore medical educators’ teaching approaches, their perceptions of their effectiveness, and the challenges they face in implementing modern pedagogical techniques.

Methods

A sequential explanatory mixed-method study was conducted. First, the Approaches to Teaching Inventory (ATI) was administered to 130 medical and dental educators in Karachi, Pakistan (71% response rate, n = 93), assessing teacher-centered (Information Transmission/Teacher-Focused, ITTF) versus student-centered (Conceptual Change/Student-Focused, CCSF) approaches. Second, semi-structured interviews were conducted with 25 educators purposively selected from the initial sample. Quantitative data were analysed using SPSS and Mann-Whitney U tests. Qualitative data were subjected to thematic analysis to identify key themes.

Results

The quantitative results demonstrated that educators often use a blended teaching approach. No significant gender differences were found in teaching experience or teacher-centric scores; however, female educators scored higher on the student-centric approach (p = 0.001). Qualitative analysis identified themes: (1) teachers as catalysts for student transformation, emphasising mentorship and practical learning; (2) curriculum challenges and the need for faculty development, highlighting dissatisfaction with outdated curricula and assessments focused on rote memorisation; and (3) teaching practices advocating for interactive methods and continuous assessment aligned with practical clinical skills. Educators expressed a desire for faculty development programs to support student-centered learning.

Conclusions

Medical educators recognise the importance of student-centred approaches but face significant challenges due to institutional pressures, outdated curricula, and inadequate assessment methods. There is a critical need for curriculum reform, adoption of continuous formative assessments, and faculty development programs to enhance teaching effectiveness. Institutions should promote environments that value pedagogical excellence and support innovative teaching practices. Aligning educators’ perceptions with actual teaching practices is essential to improve medical education and prepare students for professional practice.

Introduction

Medical education is at a critical juncture globally, facing significant challenges in adapting to the evolving needs of healthcare systems and learning preferences of contemporary students [1]. In many regions, particularly in resource-constrained settings, such as Pakistan, factors such as large class sizes, limited resources, and reliance on traditional pedagogies hinder the effective delivery of medical education [2]. For instance, overcrowded classrooms can limit student engagement and reduce opportunities for interactive learning, negatively impacting educational outcomes [3, 4]. These challenges are compounded by the increasing complexity of medical knowledge and the necessity for graduates to possess not only foundational understanding, but also critical thinking, clinical reasoning, and problem-solving skills essential for modern medical practice [5].

A fundamental element in addressing these challenges is the role of medical educators. Teachers profoundly influence students’ learning experiences, guiding them in acquiring the knowledge and developing competencies required for medical practice [6]. Effective teaching extends beyond the mere transmission of information; it involves creating an environment that promotes active learning, critical inquiry, and the practical application of knowledge [7]. However, discrepancies often exist between teaching methods and student learning styles, which can impede academic achievement and engagement [8]. Traditional teacher-centred approaches, characterised by didactic lectures and passive learning, may not align with the preferences of modern learners who benefit more from interactive, student-centred methodologies [9].

Medical educators themselves face challenges in adopting new teaching approaches due to factors such as insufficient training, resource limitations, and institutional constraints [10, 11]. The increased demands on teachers—including diverse student populations, curriculum reforms, and quality assurance requirements—add to the complexity of implementing innovative teaching methods [12,13,14,15,16]. Understanding these challenges within the local context is essential for developing strategies to support educators in enhancing their teaching practices [17, 18].

To examine teaching practices comprehensively, this study used two theoretical frameworks: positivism and constructivism. The positivist paradigm views knowledge as objective and quantifiable, and employs empirical methods to measure phenomena [19]. In the context of teaching, positivist approaches use tools, such as questionnaires, to objectively assess aspects such as student performance and teacher behaviour. For example, surveys like the Approaches to Teaching Inventory (ATI) can quantify the prevalence of teacher-centred versus student-centred methods among educators [20]. These quantitative measures provide data on teaching strategies and their correlation with student outcomes.

Conversely, the constructivist approach posits that knowledge is constructed through social interactions and experiences, emphasising the subjective meanings individuals ascribe to their experiences [21]. Qualitative methods, such as semi-structured interviews, are employed to explore educators’ perspectives and the challenges they face in implementing student-centered teaching. For instance, interviews can uncover insights into how teachers perceive the shift towards interactive learning and the obstacles they encounter, such as large class sizes or limited institutional support [22].

The current literature highlights the benefits of student-centered approaches in medical education, including enhanced critical thinking abilities, better knowledge retention, and increased student motivation [23, 24]. However, much of this research is concentrated in developed countries, and there is a paucity of studies exploring these approaches in developing nations such as Pakistan [18, 25, 26]. Furthermore, few studies have thoroughly examined medical educators’ perceptions of their teaching practices and the specific challenges they face in adopting student-centred methodologies in environments where traditional methods are deeply entrenched [27,28,29].

By integrating both positivist and constructivist methodologies, this study addresses these gaps by investigating how medical educators perceive their roles, evaluate the effectiveness of their teaching strategies, and identify obstacles they encounter when implementing modern pedagogical techniques. This mixed-methods study aimed to measure teaching approaches using established inventories, explore educators’ perceptions of their effectiveness as teachers and mentors, examine how they adopt practices that promote meaningful learning, evaluate their ongoing professional development efforts, and identify the challenges and barriers they face in their roles as educators. This dual approach is particularly innovative in the context of Pakistani medical education, where in-depth analyses are scarce. These findings are expected to inform policy and practice, offering evidence-based recommendations tailored to the specific needs and constraints of similar educational settings.

Methods

This mixed-methods study was conducted after obtaining ethical approval from the relevant Institutional Review Board. This was a sequential explanatory Quan-Qual study, in which the first phase was a quantitative component, and the second phase comprised a qualitative study. Participant confidentiality in the quantitative study was ensured by anonymously collecting data through coded questionnaires without identifying information. Informed consent was obtained, emphasising that all information would remain confidential and used solely for research purposes. Completed questionnaires were securely stored, and digital data were entered into a password-protected database that was accessible only to the research team. The data analysis focused on aggregated trends rather than individual responses, preventing the identification of any participant. The study’s confidentiality measures were reviewed and approved by the Ethics Committee to ensure compliance with ethical standards. By implementing these steps, participant privacy was rigorously maintained throughout the data collection and analysis, demonstrating a strong commitment to ethical research practices.

The study’s inclusion criteria focused on selecting faculty members with specific qualifications and experience. Faculty with postgraduate qualifications and a minimum of five years of experience teaching theoretical and clinical lessons in the medical or dental field were included. The selection criteria required participants to have published at least five scientific papers in the past five years. This timeframe was chosen to ensure that the educators included in the study were actively engaged in recent scholarly activities and were conversant with current trends and developments in medical and dental education. However, this study had some clear exclusion criteria. Educators not involved in medical education, such as those from engineering, arts, and other non-medical disciplines, were excluded. This was done to ensure the relevance and specificity of this study in the field of medical education. Visiting faculty members were also excluded, as the study aimed to analyse the perspectives of more permanent, established educators in the medical field.

Further exclusion criteria were participants with incomplete data or those who dropped out before completing all phases of the study. Such exclusions were necessary to maintain the integrity and completeness of the research data. Additionally, faculty members who failed to attend the semi-structured interviews, which were a crucial part of the study, and who did not provide a valid reason for their absence were excluded. This criterion was set to ensure that the study results were based on comprehensive and reliable input from fully engaged participants.

Quantitative study methods

Questionnaires were provided to all the postgraduate faculty available at the Dow University of Health Sciences and six other medical and dental schools in Karachi, Pakistan, with an explanation of the purpose of the study. Participants were given two weeks to complete and submit the forms, ensuring adequate time to provide thoughtful responses while maintaining the study’s schedule. The questionnaires were collected manually and represented using a positivist paradigm approach. Reminders were given for unfilled forms and were subsequently approached to be collected. Convenience sampling was used in this study. Participants were informed that they would be contacted for face-to-face in-depth interviews.

Quantitative instrument

To objectively assess teaching approaches, this study used the Approaches to Teaching Inventory (ATI), a validated instrument widely used in educational research [30, 31]. The ATI is designed to measure the extent to which educators adopt teacher-centred or student-centred strategies, aligning well with the study’s objectives of exploring instructional methods (Appendix C). The choice of the ATI over other available tools is based on its strong psychometric properties, widespread acceptance in the academic community, and its specific focus on higher education teaching practices [32, 33]. Additionally, the ATI allows for comparability with other international studies, facilitating a broader understanding of teaching approaches across different contexts [32, 34, 35].

Prosser and Trigwell (1999) classified teaching approaches into two main types: the Information Transmission/Teacher-Focused (ITTF) approach and the Conceptual Change/Student-Focused (CCSF) approach [30, 31, 34]. Within these two overarching categories, they identified five qualitatively different approaches to teaching.

• 1. Approach A: Teacher-focused strategy with the intention of transmitting information to students.

• 2. Approach B: Teacher-focused strategy aimed at helping students acquire the concepts of the discipline.

• 3. Approach C: The teacher–student interaction strategy with the intention that students acquire the concepts of the discipline.

• 4. Approach D: Student-focused strategy aimed at developing students’ conceptions.

• 5. Approach E: Student-focused strategy with the intention of bringing about conceptual changes in students.

The ATI comprises 22 items divided into two main scales: the ITTF and CCSF [20]. The CCSF scale describes an approach intended to change students’ ways of thinking through a teaching strategy that focuses on students. The ITTF scale describes an approach intended to transmit information by using a teacher-focused strategy. Each item is rated on a 5-point Likert scale, where 1 represents “only rarely” and 5 represents “almost always.” This detailed scoring system enables a comprehensive assessment of educators’ teaching orientation and provides valuable quantitative data on their instructional preferences. A total of 130 questionnaires were distributed and 93 questionnaires were returned, with a response rate of 71%.

Pretest

Before launching the main study, a pilot inventory test was conducted with 40 participants, who were not enrolled in the primary investigation. The pre-test assessed comprehension and determined the average time taken to complete the questionnaire. An expert health professional assessed the content validity of the questionnaire, ensuring that the content was appropriate and relevant for the intended audience. To evaluate the reliability of the questionnaire used in this study, we conducted an internal consistency analysis using Cronbach’s alpha. The questionnaire comprised items categorised into two subscales: Teacher-focused and Student-focused.

The Teacher-focused subscale, after the removal of questions 9 and 11, demonstrated a mean score of 3.97 with a standard deviation (SD) of 0.44. The internal consistency for this subscale was determined to be acceptable, with a Cronbach’s alpha value of 0.70. For the student-focused subscale, questions 8 and 15 were excluded to enhance the reliability. The mean score for this subscale was 4.44, with a standard deviation of 0.41. The internal consistency of the student-focused subscale was strong, as indicated by the Cronbach’s alpha value of 0.80.

The overall questionnaire, encompassing all items, yielded a mean score of 4.21 with an S.D. of 0.70. The complete questionnaire exhibited high reliability with a Cronbach’s alpha value of 0.80. These results indicate that the questionnaire, both in its entirety and within its subscales, possesses good internal consistency, making it a reliable tool for assessing the constructs of interest in this study.

Statistical analysis

For the quantitative data analysis in the study, SPSS version 24 served as the primary software tool. Differences between variables were evaluated through cross-tabulation, accompanied by the chi-square test. The central tendency of the scores was determined using the mean values. To ascertain the significance of the relationships between variables, p-values were used.

Qualitative study methods

Guided by the constructivist framework, this study used semi-structured interviews to investigate medical faculty members’ perceptions of their teaching and professional development. Faculty members with both high and low ATI inventory scores were selected for interviews. Participants were equally divided between medical and dental educators, with half from medical colleges and half from dental colleges. Additionally, there was an equal mix of faculty from the government and private institutions, totalling 25 experienced educators who were purposively selected for in-depth qualitative interviews after providing informed consent.

The selection criteria included factors such as availability, previous connection to the researcher, seniority, and their roles within their institutions. This study acknowledges that bias is an inherent aspect of qualitative research, primarily when prior relationships exist between the researcher and participants. Recognising that complete objectivity is unattainable, several measures were implemented to mitigate potential biases and enhance the study’s validity and credibility. The researcher engaged in reflexivity by continually reflecting on personal biases and and how these might influence data collection and interpretation, aiming to minimise subjective influence. Reflexivity was further maintained through the use of a reflective journal, allowing the researcher to document and critically examine personal thoughts and potential biases throughout the research process.

To ensure the accuracy and credibility of the data, after transcribing the interviews, the transcripts were shared with the participants for their review. This process, known as member checking, allowed participants to confirm the accuracy of their statements and add additional thoughts, ensuring that their perspectives were authentically represented. Direct quotes from participants were included in the analysis to accurately convey their viewpoints, thus reducing the influence of the researcher’s interpretations. The study deliberately selected a diverse group of participants, equally divided between medical and dental educators, from both government and private institutions. This diversity minimised the impact of any single relationship on the overall findings. The participants were assured of complete confidentiality and anonymity, encouraging honest and open communication. The interviews were conducted in a neutral, private setting to reduce any potential discomfort or power dynamics stemming from prior relationships. A standardised semi-structured interview guide was used to maintain consistency across all interviews, minimising the likelihood of the researcher’s prior knowledge influencing participants’ responses. Additionally, the co-authors independently reviewed the data and analyses to identify and correct any potential biases in interpretation. By transparently acknowledging the inherent biases and implementing these measures, this study aimed to ensure that the findings accurately reflected educators’ perspectives and experiences while maintaining ethical research practices. The interviews were audio-recorded for research purposes and were accessible only to the researcher and study supervisor.

The interviews began with general questions about the teaching experience and gradually narrowed down in focus, with minimal interruptions to guide the conversation towards the study’s objectives. The researcher refrained from injecting personal views into the discussion and used neutral probes to facilitate the flow of the interview.

The semi-structured interviews comprised eight main questions and probing items for further clarification (Appendix A). The duration of the interviews ranged from 40 to 60 min. All interviews were conducted in English and the participants’ preferred language. In a study that included qualitative data, such as this one, the study’s primary outcomes were the identification and analysis of recurring themes from semi-structured interviews. This could offer insights into everyday challenges and best practices for teaching effectiveness and student learning. Interviews were transcribed verbatim. All audio recordings were converted manually into text. This transcription process was followed by a qualitative content analysis [36]. Qualitative content analysis is instrumental in understanding phenomena and social realities by using written data. A significant advantage of this method is its capability to analyse large datasets without the risk of unwanted interaction effects between the participant and researcher [37].

The analysis involved identifying 94 different codes across the scripts, which facilitated the development of conceptual ideas beyond mere descriptions, as shown in Appendix C. These codes were subsequently categorised into themes. The data were treated as a unified entity and analysed following McCracken’s (1988) five-step method [38]. In the first step, the transcripts were read thoroughly with notations made in the margins to highlight the initial observations. The second step involved developing these observations into preliminary descriptive and interpretive categories, informed by evidence from the transcripts, relevant literature, and guiding theoretical frameworks. The third stage examined these preliminary codes more closely to identify connections and to develop pattern codes. In the fourth stage, basic themes were determined by analysing clusters of comments from respondents and memos made by the researchers. The fifth and final stages entailed examining these themes across all interviews and identifying the predominant themes that emerged from the data. These predominant themes served as answers to the research questions and formed the foundation for the data write-up. Additionally, field notes were consistently taken during the interviews to capture the respondents’ expressions and impressions. This practice was instrumental in understanding the unspoken elements and provided valuable context during the data analysis phase.

Sample size estimation

Convenience sampling was performed in this study. For the quantitative part, which used the Approach to Teaching Inventory (ATI), power analysis helped identify the required sample size to detect an expected effect with a given level of confidence and power. To detect a medium effect size (Cohen’s d = 0.5) with 80% power and a significance level (alpha) of 0.05 was used. Under these assumptions, a two-tailed t-test required a sample size of approximately 128 participants to detect a statistically significant effect [39].

In many real-world research settings, particularly in specialised fields like medical education, there may be constraints on the number of available participants. Given resource limitations, a sample size of 128 participants may represent a sizable proportion of the available population and may be the maximum feasible size. A sample size of 128 is suitable for various statistical tests, such as t-tests, ANOVA, and multiple regression, provided that the number of predictors is not too large. It can also allow for stratified analyses by subgroups if needed. While convenience sampling has drawbacks, such as potential bias and limited generalizability, it is sometimes the most practical method [40].

Qualitative studies often use the concept of “saturation” to determine the sample size [41]. This is typically when no new information or themes are observed in the data. The qualitative sample is supposed to be a subset of the quantitative sample for more in-depth exploration. However, only a quarter of the sample size was used in the qualitative study, with 25 purposively selected participants.

Results

Quantitative data analysis

A quantitative analysis was conducted to compare teaching experience in years between male and female educators (Table 1). The Mann-Whitney U test was employed to evaluate whether there were significant differences in teaching experience based on gender. The mean rank for teaching experience was higher for male educators than for female educators. The results indicate that the difference in teaching experience between male and female educators was not statistically significant (p = 0.154), suggesting no significant difference in teaching experience between male and female educators, as indicated by a p-value greater than 0.05.

Table 1 Gender-wise comparison of teaching experience

The Mann-Whitney U test was conducted to compare teacher-centric scores between male and female teachers, as shown in Table 2. The results indicated that the mean rank for male teachers (N = 43, 46.2%) was 44.48, whereas the mean rank for female teachers (N = 50, 53.8%) was 49.17. The p-value obtained from the test was 0.401, which is greater than the conventional threshold of 0.05. This suggests that there was no statistically significant difference in teacher-centric scores between male and female teachers. The Mann-Whitney U value was 966.50. The analysis indicated that gender did not significantly influence the teacher-centric scores.

Table 2 Gender-wise comparison of teacher-centric score

The Mann-Whitney U test was conducted to compare student-centric scores between male and female teachers (Table 3). The results indicated that the mean rank for male teachers (N = 43, 46.2%) was 37.37, whereas that for female teachers (N = 50, 53.8%) was 55.28. The p-value obtained from the test was 0.001, which was less than the conventional threshold of 0.05. This finding suggests a statistically significant difference in student-centric scores between the male and female teachers. The Mann-Whitney U value was 661.00. The analysis indicated that gender significantly influenced student-centric scores, with female teachers scoring higher than their male counterparts did.

Table 3 Gender-wise comparison of the student-centric score

Qualitative data analysis

The interviews aimed to gather insights into teachers’ perceptions of their teaching experience and professional development. Through the qualitative content analysis of all interviews, various themes emerged. These themes were condensed and brief names that conveyed their semantic meanings were assigned. Three distinct themes were identified:

• The role of the teacher as a driving force.

• Challenges related to the curriculum and faculty development.

• Practices related to teaching and learning applications.

Table 4 Thematic analysis table

Teacher as a driving force

All participants in the interviews understood the role of the teacher in influencing student transformation. Having experienced the same journey as the students, they recalled the challenges and obstacles they had encountered during their undergraduate education. One of the teachers expressed:

During my student years, teachers who did not show much interest in us and did not allow us to study extensively or motivate us, until today … those are the subjects I lack knowledge in, and I do not know anything about them. (TF11)

Three respondents mentioned that during their undergraduate studies if they had not learned any topic or chapter well or had been motivated to acquire knowledge from the teacher, it resulted in their inability to cope with the practical world. This could have been a permanent setback in their profession until they returned and relearned the material. The last 15 years can be considered as a period of evolution for medical and dental education in Pakistan. This change ensued after postgraduate teachers returned from studying abroad. They introduced innovative ideas and the highest standards to reform Pakistan’s education system.

A teacher can build the future of the particular field by only one lecture… it takes only one lecture, in my opinion, to inspire someone, and it can also take one lecture to destroy that image of that subject. (TF22)

They discovered fulfilment through the success of their students, and being part of the teaching profession granted them a sense of esteem. Recognising that teachers serve as the primary catalyst for enhancing student performance, they derive job satisfaction from their role as educators.

I hold the belief that teaching and lecturing individuals, encouraging my students to evolve into better professionals, serves as a source of both encouragement and satisfaction for me. …… Additionally, I instil in them the notion that teaching is a wonderful field to pursue, as it allows one to contribute back to the community they originate from, much like the dental community. (TF2)

Three out of the six teachers expressed that their teaching methods constantly evolved as they actively learned new approaches and experiments through trial and error. They emphasised that not all students possess the same level of aptitude; hence, it is imperative to tailor teaching to their cognitive abilities and remain adaptable to change.

Curriculum challenges and faculty development

In response to inquiries about the curriculum, certain teachers voiced discontent with its structure, raising concerns regarding its overall quality and coverage. A notable number of interviewees were mainly dissatisfied with the four-year duration of the BDS (Bachelor of Dental Surgery) program and what they perceived as an inequitable distribution of time slots for subjects.

Yes, transitioning from clinical aspects back to the fundamentals, numerous elements need to be integrated. The mode and method of teaching must evolve, and efforts are underway in this direction. However, I believe it will require some time to see significant changes. (CF9)

They emphasised the insufficient coordination and integration among subjects, along with a deficiency in fundamental professionalism knowledge such as ethics. Furthermore, they highlighted the disconnect between the curriculum and degree programs. They also advocated revising the curriculum and suggested removing outdated and irrelevant topics. Most interviewees expressed discontent with the current curriculum, highlighting that students only received clinical exposure to patients during their final years. This limited timeframe does not adequately equip students to become competent in their treatment planning.

Consequently, graduates may enter an unprepared workforce, potentially lagging their counterparts. Another interviewee emphasised the importance of exposing students to clinical scenarios right from the outset. By spending time with patients and engaging in communication, students develop a deeper understanding of their patients, laying the groundwork for their comprehension from the pre-clinical stage. Integrating clinical subjects at the beginning of their professional education promotes connections between theoretical and practical knowledge. Students must engage in clinical scenarios to fully grasp and apply their learning, thereby instilling motivation.

There was unanimous agreement regarding examinations that the purpose should not be to fail students but rather to encourage them to provide answers. There is a prevailing argument against the effectiveness of relying solely on one-day annual exams to evaluate a student’s performance over an entire year, as this approach can be detrimental. Implementing standardised exams and assessing student performance through continuous evaluation is essential.

The assessment program should revolve around observing the student or postgraduate within the department, evaluating their methods and approach daily, rather than relying solely on a single day’s performance, which could be influenced by a bad day and may not be the most reliable measure. (CF6)

They stressed that modern students often prioritise passing exams over genuine learning. Therefore, evaluating them based on their professional attitude and communication with patients is vital, recognising that exam scores alone do not reflect their true capabilities.

Teachers also expressed dissatisfaction with the current examination grading system, advocating for reduced viva components, and increased skill-based assessments. They observed that the modern assessment method, the Observed Structural Clinical Exam (OSCE), is often misused and functions primarily as a recall test at spotting stations. They proposed boosting internal evaluation marks to give greater importance to students’ continuous formative assessment.

……assessment primarily relies on viva, clinical, and skills evaluations now. Over the past three to three and a half years, we have transitioned from the traditional viva format to a more contemporary approach. This shift allows us ample time to thoroughly assess the breadth and depth of the subject matter, enabling students to demonstrate greater competence and achieve higher scores. (CF2)

All interviewed teachers emphasised the necessity of faculty development programs. Each participant participated in two or more short courses, from paper-setting workshops to lecture development sessions. They explicitly stated that their teaching methods and assessment approaches underwent noticeable changes after participating in the course.

It stems from the fact that initially, you need to standardise and educate your faculty because students will learn what we teach them. If the faculty lacks understanding… (CF8).

It is imperative for subject specialists to collaborate in integrating course topics across various disciplines and promote adaptability within the system. However, one teacher expressed discontent with senior faculty members’ reluctance to embrace modern teaching methods while noting that junior faculty members are often excluded from workshops, which could adversely affect future outcomes. Sincerity, teamwork, and coordination are crucial elements for departmental success. While all participants acknowledged that change is gradual and may require time for teacher acceptance, they concurred on the necessity for ongoing workshops to facilitate this process.

Practices related to teaching and learning applications

All the interviewed teachers displayed strong motivation to teach and facilitate student learning. They viewed themselves as facilitators, aiming to assist students rather than provide spoon-feed by outlining essential topics. Their approach involved incorporating more clinical scenarios and practical images, and minimising textual content to stimulate brain activity from the outset.

….First, we presented them with pictures and videos, followed by hands-on activities. I believe that this approach is more effective than showing slides, as most people forget information presented in that format after just five minutes. However, with pictures, the memory retention is much stronger. So, I utilise clinical experiences, initiate discussions, display pictures, and engage in dialogue to enhance learning…. (PT4)

It was also determined through interviews that teachers recognise their responsibility to possess in-depth knowledge about the topic before delivering their lectures. They also noted that their most successful lectures were when they were thoroughly prepared and had comprehensive command of the subject matter. Additionally, many teachers allocated the last 15 min of their lectures to planning question-and-answer sessions and discussion sections.

They also integrated assignments to familiarise students with the topic and provided feedback on their performance. Two teachers consistently sought student feedback to understand their problems and difficulties. Measures were taken to address or revisit topics and enhance teaching methods accordingly. Creating opportunities for learning and using the latest technology to provide students with platforms are essential for effective learning.

Furthermore, teachers emphasised that good teaching involves conceptual clarity and serving as role models, while poor teaching merely involves transferring knowledge. They assessed their students through quizzes and small exercises, and prepared open-ended short questions in assignments to encourage students to write, followed by multiple-choice questions. One teacher mentioned that lectures are not as crucial since students are self-directed learners. Excessive lecturing and information overload do not necessarily produce better outcomes, as students learn most effectively through independent study.

Students learn at their own pace and prefer to study independently, regardless of the number of lectures or demonstrations provided. There have been instances where extensive teaching efforts yielded the same results, and conversely, when we reduced teaching activities, we achieved the same outcomes. Do you see the difference ….? (PT23)

When collaborating on new teaching techniques, their peers encountered difficulties, particularly in the presence of senior faculty members. Resistance to modern methods was observed among senior faculty members whose experiences often hindered change. Communication gaps arose when junior and senior faculty members collaborated.

Teachers also faced institutional pressure when questioned regarding this issue. It was explained that seven colleges had transitioned to a centralised system under one University for examinations, creating a competitive environment. Teachers’ performance was assessed based on their students’ grades on the annual exam, leading to institutional pressure to produce positive results. There were also inquiries regarding whether the students failed. They recognised that this approach promotes rote learning among students, as high statistics in results do not guarantee skilled professionals.

One teacher expressed frustration that the higher administration failed to grasp the needs of teachers for student learning. They emphasised the importance of considering updated materials and tools to better prepare students for their professional endeavours.

Resource materials requested for teaching and learning should be provided by the department, and it is something the administration really needs to prioritise. Whether it is a requested instrument or any other material, it is crucial for them to take it into account because we aim to benefit the students. With advancements occurring daily, not only in my speciality but in dentistry, students’ access to these advancements is quite limited. (PT20)

Discussion

The ATI has proven to be a simple, quick, and efficient tool for evaluating teaching approaches among medical educators in a resource-constrained setting. Its 5-point Likert scale facilitated easy comprehension and alignment with the situational stems in the inventory [31, 34]. Observing predominantly high-to-moderate scores on both the ITTF and CCSF scales among respondents suggests that educators employ a blended approach, aiming to transmit information while also encouraging conceptual changes in students.

During informal discussions, faculty members initially had concerns about whether the ATI questionnaire accurately measured what they intended to assess. However, upon observing their own scores and the corresponding scales, they agreed that their teaching approaches were reflected in the results of the questionnaire. This realisation mitigated their scepticism and reinforced the instrument’s validity in capturing teaching approaches among educators in our context.

There was also a consensus regarding the obsolescence of current assessment methods compared to those used in international medical education systems. Educators acknowledged that they often focus on imparting knowledge to ensure students’ success in annual exams, driven by institutional pressure to achieve favourable results. This emphasis may inadvertently prioritise information transmission over deeper learning strategies.

This study integrates both positivist and constructivist paradigms to provide a comprehensive analysis of teaching practices. The positivist approach aligns with the use of ATI, employing quantitative methods to objectively measure observable phenomena such as teaching strategies and their correlation with student outcomes [42]. For example, the ATI scores revealed the prevalence of teacher-centred versus student-centred approaches among educators, allowing for statistical analysis of patterns and relationships.

Conversely, the constructivist paradigm involves qualitative methods to explore educators’ subjective experiences and perceptions [43]. Semi-structured interviews captured the complexities of teachers’ challenges in implementing student-centred teaching, such as adapting to new roles or managing resource constraints. These interviews provided rich, contextualised data that deepened the understanding of the factors influencing teaching practices.

By combining these paradigms, this study captured both the measurable aspects of teaching approaches and the underlying experiences that shape them. This comprehensive methodology enhances the validity of the findings and contributes to a more comprehensive understanding of medical education challenges in the local context.

In our study, the emphasis was on exploring where educators fell between ITTF and CCSF types. The ATI measures these approaches, allowing us to assess whether educators are more teacher-focused or student-focused in their teaching strategies. Our findings indicate that educators often employ a combination of these approaches to reflect a blended teaching style. They aim not only to transmit information but also to facilitate conceptual understanding and change among students. This blended approach aligns with Approach C, where there is teacher–student interaction with the intention of students to acquire disciplinary concepts.

Connecting the broader theoretical framework to our findings, it becomes evident that teaching approaches are influenced by educators’ perceptions of their roles and educational contexts [44, 45]. Teachers who aim for student comprehension acknowledge that knowledge is socially constructed through interaction [46]. They served as facilitators and created platforms for self-directed learning. In the Pakistani medical education system, this shift towards student-centred learning is crucial for producing competent professionals equipped to meet contemporary challenges.

Our interviews provided profound insights into teachers’ styles and challenges in undergraduate teaching. Teacher identity is complex and multifaceted, encompassing aspirations to excel, desires to reform practices, and management of multiple roles [47]. Educators expressed that appreciation from institutions enhances job satisfaction and performance, emphasising the need for institutional support in promoting effective teaching.

Quantitative analysis revealed no significant gender-based differences in teaching experience or use of teacher-centric methods (Table 1). However, female educators scored significantly higher on student-centric approaches (p = 0.001), as shown in Table 3, indicating a greater inclination toward methods that promote active engagement and deeper learning. This suggests that female educators may be more attuned to the benefits of student-centered methodologies, which are valuable in medical education, where critical thinking and practical skills are paramount.

The thematic analysis of the interview transcripts revealed several key themes related to assessment practices, the role of teachers, curriculum challenges, and faculty development (Table 4). Educators expressed concern that current examinations focus more on recalling factual knowledge rather than assessing practical skills. This critique aligns with literature emphasising the limitations of traditional assessment methods in medical and dental education [48]. Traditional written exams often fail to evaluate higher-order cognitive skills and clinical competencies essential for professional practice [49]. The reliance on factual recall does not adequately prepare students for real-world clinical scenarios, where critical thinking and practical skills are paramount [50, 51].

Furthermore, educators have highlighted the importance of assessing students’ professionalism, communication skills, and overall attitudes. Assessing these attributes is essential for producing well-rounded practitioners. Professionalism is a core competency that should be explicitly taught and assessed [52, 53]. Holistic assessment approaches, such as multisource feedback and portfolio assessments, comprehensively evaluate students’ abilities, including interpersonal skills and ethical behaviour [54]. However, this study found that the current assessment practices lack assessment of professionalism.

Educators advocated for continuous assessment rather than relying solely on summative evaluations. Formative assessments provide ongoing feedback, enhance student learning, and identify areas requiring improvement [55, 56]. In dental education, continuous assessment can better track the development of clinical skills and professional behaviors over time, ensuring that students meet the required competencies before graduation [57].

The need for faculty development to improve assessment practices was emphasised, particularly concerning using OSCEs. Educators noted a misalignment between the intended purpose of OSCEs and their application, with OSCEs being used for tasks like “spotting” rather than assessing clinical competencies. Faculty development programs are essential to train educators in designing and implementing appropriate assessment tools, ensuring that tools such as OSCEs are used effectively to evaluate the intended competencies [58].

Teachers acknowledged their significant influence on student transformation, emphasising mentorship, practical learning, and the ability to inspire. Past negative experiences motivated them to improve their teaching methods, highlighting the critical role that educators play in shaping student attitudes and career paths.

Dissatisfaction with the current curriculum was evident. Teachers advocated for integrated subjects and continuous assessment to better prepare students for professional demands. They stressed the necessity of early clinical exposure to bridge the gap between theory and practice, aligning with studies highlighting the importance of practical learning in medical education [59, 60]. Faculty development workshops were deemed essential for equipping educators with modern teaching techniques. Educators emphasised thorough planning, interactive methods, and incorporating clinical scenarios into lectures. Continuous feedback from students was identified as vital for enhancing engagement and understanding. These strategies align with constructivist theories advocating active learning and student involvement in knowledge construction [61].

Implementing student-centric approaches poses challenges, especially in rigorous disciplines such as medical science [62]. Shifting such an approach requires time, strategic planning, and institutional support [63]. Teachers need to consider students’ prior knowledge using discussion groups, practical case studies, and interactive sessions to facilitate understanding [64, 65].

Integrating positivist and constructivist paradigms allowed this study to capture both the measurable aspects of teaching approaches and the underlying experiences that shape them. The quantitative data showing high scores in both ITTF and CCSF approaches reflect a blended teaching style, while qualitative insights emphasise the necessity for practical, interactive methods and improved assessment practices. This comprehensive methodology enhances the validity of the findings and contributes to a more holistic understanding of the challenges of medical education in the local context.

This study advocates enhancing high-quality teaching through the Scholarship of Teaching and Learning (SoTL) model developed at the Karolinska Institute [66]. SoTL is a professional approach that seeks to improve student learning through systematic inquiry and peer review [67]. By critically examining their teaching practices, implementing interventions, and sharing outcomes, educators can enhance both student learning and their own professional development. The SoTL model outlines six steps: exploring existing knowledge, developing practices, investigating problems by framing research questions, documenting findings, undergoing peer review, and sharing results publicly [68]. Engaging with SoTL not only benefits students but also offers educators opportunities for recognition and scholarly contribution. Institutions are encouraged to support faculty in adopting the SoTL model and developing a culture of continuous improvement and educational excellence in medical education [69].

Senior university leadership can use these insights to reflect on governance structures and realign strategic goals with faculty and student needs. Collaborative discussions on learning objectives across departments can enhance curriculum coherence. Institutions should consider revising assessment strategies to emphasise skill development, professionalism, and continuous feedback. Faculty development programs play a crucial role in this transition, ensuring educators are equipped to implement and utilise assessment tools effectively.

This study has some limitations affecting the generalizability of its findings. The use of purposive sampling and a relatively small sample size limit the extent to which results can be applied to broader populations. The reliance on self-report measures introduces potential biases, including social desirability bias and inaccuracies in self-perception. However, the insights gained are applicable to similar resource-constrained settings, where educators face comparable challenges. These findings can inform educational strategies in other regions with similar limitations.

Additionally, while initial scepticism about the validity of the ATI questionnaire existed among faculty members, their concerns were alleviated upon reviewing their own scores and scales. They agreed that their teaching approaches were reflected in the results of the questionnaire, reinforcing its applicability in this context. However, future studies should consider using multiple validated instruments to comprehensively assess teaching practices.

Conclusions

This study examined medical educators’ perspectives on teaching effectiveness and student learning in a resource-constrained, low-middle income country. The findings revealed that educators employ a blended teaching approach that combines information transmission with efforts to encourage conceptual understanding. Many educators recognise their significant role in influencing student transformation through mentorship and practical learning, motivated by past negative experiences to improve their teaching methods.

Despite identifying themselves as student-focused, discrepancies between educators’ perceptions and their ATI scores suggest a need for a better alignment between intended and actual teaching practices. Educators expressed concerns over outdated assessment methods that overemphasise factual recall and inadequately assess practical skills and professionalism. There is a call for continuous formative assessments to provide ongoing feedback and better track the development of clinical skills and professional behaviours.

This study highlights widespread dissatisfaction with the current curriculum, emphasising the need for greater integration, continuous assessment, and early clinical exposure to bridge the gap between theory and practice. Faculty development workshops are essential for equipping educators with modern teaching techniques and improving overall teaching effectiveness. Both quantitative and qualitative data underscore the necessity for practical and engaging teaching methods to enhance learning outcomes.

Addressing these challenges requires revising the curricula, implementing continuous formative assessments, and supporting ongoing faculty development. Adopting models such as SoTL can cultivate a culture of continuous improvement in teaching methodology. Institutions can improve the quality of medical education by valuing pedagogical excellence and encouraging innovative teaching and assessment practices, ultimately preparing students for professional practice and enhancing patient care.

In essence, this study emphasises the crucial role of teachers in enhancing student learning and the importance of aligning educators’ perceptions with their actual practices. Implementing faculty development workshops and revising curricula and assessment methods is imperative to ensure that student learning is meaningful and effective.