A cross-sectional study was carried out to evaluate the fourth year medical students' perspectives on quality of FM education at FOM/SCU in the educational year 2017/2018 and to determine the associated factors of students' learning experiences in FM module.
In the present study, more than half of participants positively perceived attending field training in improving their competencies, FM module in improving their consultation and communication skills, assessment covering many ILOs and OSCE as a satisfying tool of assessment.
Participants felt the presence of unwanted academic pressure on them, too many topics of the syllabus, the unsatisfying of library resources for their needs, the heaviness of workload, the difficulty of MCQs and unhelpful portfolio guide.
Near half of participants were satisfied with FM module. The predictors of their satisfaction were learning resources and good teaching. Availability of frequent live lectures was the most frequent suggestion of participants.
Participants' perceptions towards satisfaction with FM module
In the current study, the student's overall satisfaction with the quality of FM module had a mean score of 3.34. This questionable perception does not conflict with the need for continuing quality improvement of FM module to satisfy more students, even if FM module did not perceive negatively yet.
In the Park's study, the mean scores of the fourth year students' overall satisfaction with FM at Dankook university hospital and a community hospital or clinic in Cheonan, Korea, were 4.5 and 4.3 on a 5-point scale, respectively . The sound comparison could not be made due to different methodology of these studies.
Participants' perceptions towards learning resources
In the current study, participants'' perception towards learning resources was the most predictor of participants' satisfaction, this might be due to training in PHC settings, the availability of e-learning website in FM for fourth year medical students, and materials of FM module were clear, concise, relevant and up to date, which had positive impacts on their learning and assessment.
Training in PHC settings might able participants to become health provider dealing with the common health problems among children and women in the community, health educator, professional, member of PHC member and an active learner. E-learning website included interactive MCQs, lectures, learning videos, quizzes, assignments, interact with staff/co-staff and students and orientations about the OSCE, clinical exam and written exam. The structured assessment of this e-learning was out of this research scope.
Despite the majority of participants positively perceived improvement of their competencies by training in PHC setting, the mean score of participants' perceptions toward this item was questionable in the present study. This finding was consistent with finding in another study among pregraduate medical students enrolled in FM rotation at Wuppertal PHC and Research Center in Wuppertal, Germany .
Participants had negative perceptions towards appropriability of traditional library resources for their needs (the mean score was 2.76), this might a result of using information technology in education and availability of lectures' material helping their learning. This finding is consistent with Salama and Nour-Eldein finding where students reported perceptions with a mean score of 2.66 . These findings reflected shifts in education methods and the impact of computer technology.
The portfolio is evidence that students mastered the required skills and achieved the objectives of FM. It included ILOs, personal learning plan, list of cases during FM round, the required practical and clinical skills to be fulfilled and signed by trainers at the end of FM round, two evidence-based medicine case studies, professionalism evaluation form, self-reflection on their learning and scoring criteria of the FM fourth year portfolio. It seemed that students' perceptions with portfolio as hardworking paper takes time outweighs its importance, so, their perceptions were negative in the present study.
Participants' perceptions towards good teaching
Good teaching was the second predictor of participants' satisfaction, this might be due to tutors at field training and the designers of the e-learning website worked hard to make the FM subjects interesting. Trainers at field work were extremely good at discussing health problems, which students encountered at PHC settings, made a real effort to understand any difficulties they had during learning and with the PHC team or clients and gave helpful oral feedback to students on their progress and document relevant feedback on their portfolio.
Participants' perceptions towards generic skills
In the present study, majority of participants had positive perceptions about improvement of their consultation and communication skills after attending FM module. This result was consistent with a result of a systematic review on impact of FM clerkships in undergraduate medical education .
Participants were skeptical about sharping of their analytic skills by FM module in the present study. Kavukcu et al found medical students were doubtful about well-developed problem solving skills after FM rotation  and authors considered that not bad but need improvement.
Participants' perceptions towards intellectual motivation
In the current study, participants reported questionable perceptions about FM module's education as stimulating. In another study in Germany, students perceived positively teaching FM as often stimulating . This difference might be the result of differences in the environments of learning.
Participants' perceptions towards clear outcomes and standards
In the present study, participants had questionable perceptions with a clear idea of where they were going and what there were expected. This might be the result of negative participants' perceptions with the usefulness of portfolio guide and they spend relatively short time in studying FM compared with others module in the primary care course. This finding was congruent with Kavukcu et al.'s finding .
Participants' perceptions towards appropriate assessment
Assessment in FM module included varieties of assessing methods. In the current study, the' mean score of participants' perceptions towards satisfaction with OSCE was the higher than others learning experiences' mean scores; this finding might be due to OSCE exam was consisted of 12 stations, covering a wide range of ILOs, with adequate time of stations and clear candidate instructions, having educational impacts on them and extensive explanations about what would be covered in the OSCE were provided to students via e-learning website.
In another study, the final year medical students valued the OSCE as a tool of assessment in FM course at FOM, Qassim University in Kingdom of Saudi Arabia with a mean score of 0.33 . Direct comparison with this study was difficult due to different methodology of these studies.
In the current study, participant perceived difficulty of MCQs. Actually, pre-validation of the MCQs’ was done by the examination committee at the FOM/SCU. Automated grading of MCQs was done, but post-validation of MCQs by testing difficulty index is needed to confirm these perceptions about quality of MCQs.
Participants' perceptions towards the appropriate work load
In the present study, the participants' felt workload was inappropriately high and the presence of too much unwanted academic pressure on them; these might be due to uncomfortable transport to training PHC centers in another governorate and spending a lot of time during traveling. Kavukcu et al found that participants positively perceived with enjoyment outweighs the stress of FM course . Sound comparison is difficult due to different methodology and learning environments.
Students' opinion about advantages of FM module:
In the present study, participants reported advantages of FM module, e.g. improvement in their communication, history taking and consultation skills and learning how to manage common health problems at PHC settings. These advantages were reported in previous studies with different percentages due to different learning environments [13-15].
Student suggestions for improving quality of FM module:
In the current study, participants suggested more live lectures because of they didn't receive any live lectures during FM module. They also recommended adding more time for the module and more time for clinical practice teaching at PHC settings. Cooper reported similar suggestions were; the attachment should be longer, greater involvement of the student, and more teaching of practical skills .
Associated factors with participants' learning experiences
There were no significant associations between satisfaction and learning demographic variables in the present study. This was incongruent with Salama and Nour-Eldein finding where there was a statistically significant relationship between satisfaction with FM module and female gender .
Generic skills were strongly positively correlated with intellectual motivation Participants' satisfaction was predicted by learning resources and good teaching. Studies into associated factors or predictors of quality of undergraduate FM education seem to be scarce, so it is difficult to make sound comparison.
Limitations of the current study:
The generalization of this study's results is limited by lack of randomization. The study is not designed to address the cause effect relationship of teaching quality in FM; it can only suggest an association for further research.