Educational environment consists of many factors such as physical environment (e.g., classroom and equipment), teachers, colleagues and other student support systems that can motivate the engagement of the learner. ¹ It is an important part in the curriculum that has been reported to be associated with student’s satisfaction, academic achievement and effectiveness of learning. ² Assessment of student’s perception on educational environment may help provide medical schools with barriers and opportunities for improvement of learning experiences in medical students. ³ Educational environment has become an essential area for medical education program evaluation by many authorities such as the World Federation for Medical Education (WFME). ⁴

Many tools have been developed for assessing student perception of educational environment. Most previous studies reported ‘more positive than negative’ learning environment.It is also suggested that perceived educational environment may be related to a number of factors such as student’s sex, study years and academic performance, and characteristics of medical schools. ^{5 - 15} However, most of the previous studies described student perceived educational environment in a single or small number of medical schools; national data were scarce. ^{8 - 15} National data would allow comparisons of learning environment across different medical schools or teaching facilities, hence benchmarking can be done and used as a tool for improvement. There is a lack of evidence to describe educational environment perceived by clinical year students in medical schools in Thailand. Further, it remains unclear if the perception is related to certain characteristics of medical students and teaching facilities.

The objective of the present study was to examine the perception of educational environment among clinical year medical students trained at 34 teaching hospitals across Thailand and to identify factors associated with overall educational environment scores and subscales.

This paper describes medical student’s perception of educational environment in 34 teaching hospitals nationwide using a Thai version of DREEM questionnaire. Overall, the medical students perceived more positively than negatively about their learning environment, although a small number of students felt dissatisfied. Students trained in teaching hospital of different sizes perceived differently about their learning environment, while student sex and year of study were associated with certain subscales of educational environment.

Similar to our findings, previous studies from Australia, Sweden and the United Kingdom reported that there were ‘more positive than negative’ student perceptions regarding learning environment and atmosphere as a whole, with a small proportion of students reporting ‘excellent’ or ‘poor’ learning environment. ^{9 , 17 - 19} A few national-level studies have been done in medical students, and they similarly reported a wide range of global score of learning environment. ^{20 , 21} This observation may be expected due to a great variety of medical schools across the countries. Noteworthy, our study showed a higher average total DREEM score and narrower standard deviations than that from national surveys in Korea and Brazil (131.1 (SD 17.3), 114.0 (SD 21.6) and 119.4 (SD 27.1) respectively).

Although this does not imply absolute advantages of Thailand’s medical schools over those in the two countries, it suggests that overall learning environment in teaching hospitals in Thailand relatively meet most students’ expectations. It also suggests that educational environment and atmosphere were fairly consistent across 34 teaching hospitals of Thailand.

Student’s perceptions on learning environment and atmosphere provide valuable information for curriculum development and improvement of medical schools. The DREEM questionnaire and similar other tools were designed to describe several aspects of learning environment ranging from teachers, atmosphere, supporting facilities to student’s academic self-perception. Therefore, they can be used to identify strengths and limitations of medical schools, which may form key parts of the framework for improvement of medical schools themselves and to benchmark with other medical schools. As shown in our study, teachers appeared to be one of the key strengths of Thailand’s CPIRD teaching hospitals. This might be because CPIRD particularly have continuously improved its teacher-to-student ratio and faculty development. On the other hand, it seemed that atmosphere and social self-perceptions were among the crucial areas for improvement. To address these issues, a number of interventions may be implemented, such as stress management program, and social and academic support for medical students to develop self-resilience. In addition, student support and guidance such as effective mental health program and advising/ mentoring program may also be beneficial. ^{22 , 23}

Student perceptions on educational environment and atmosphere may change over years of study as the result of interaction between student experience and varying challenges over time. In the present study, although overall perceptions on learning environment were consistent across years of study, students’ academic and social self-perceptions and perception of atmosphere were increasingly positive when they advanced to a more senior year. This is in contrast with many previous studies which showed the decreasing trend of DREEM scores over years of study. ^{9 , 10 , 24 , 25} This may suggest different student’s ability to adapt themselves to evolving challenges such as clinical tasks and assignments when advancing through more senior years, or may simply reflect discrepancy in medical curriculum in these countries. Another explanation for such findings might lie upon the ability of a tool to capture complete aspects of clinical training in different years of study. Questionnaires to measure educational environment should be more contextualized and specific to clinical years of medical study. One example is a tool called Teaching and Learning Climate or TLC, which includes additional items on ward environment, colleagues such as residents, house officers and nurses, and learning experience related to clinical tasks and assignments. ²⁶

Gender inequality in perceptions of educational environment has been consistently reported. Similar to previous several studies, ^{9 , 12} our study showed that female medical students had more positive perception on learning environment than their male counterparts, particularly on teachers. A more positive perception of teachers in female students might be due to different learning styles of the two sexes or simply gender bias towards female students in teaching and evaluation. ^{27 , 28} In addition, more positive academic self-perception in male students may partly be because male medical students seemed to be more confident in their academic performance than female students. ²⁹

Size of medical schools may have influence on educational environment, with some evidence suggesting favorable learning environment in small-sized medical schools. Similar to the previous studies in Australia and Canada, ^{13 , 17 , 30 - 32} our study found that students in small-sized medical schools and training facilities perceived more positively about their learning environment than those from a larger medical school. This may be explained by that small sized teaching hospitals may provide closer teacher-student and student-student interaction. In addition, large sized teaching hospitals are usually equipped with highly sophisticated medical technologies and taught by subspecialty medical staffs. This may be less relevant to training of medical general practitioners than small sized hospitals. Hence, students at smaller medical training centers may be more satisfied with their educational experience than those trained at the larger training centers. ^{13 , 17}

CPIRD is a good demonstration that using existing health services as training facilities helps enhance student’s experience in community-oriented competencies and interprofessional skill. ³³ Previous studies suggests that medical teaching in service hospitals may also help equip students with better clinical competency as compared to teaching in large university hospitals. ^{33 - 35} Training in real healthcare services may provide students with hands-on experience on clinical practice and procedures, which are more relevant to their future career practice. Many authorities have suggested that doctors should be produced in real health service system with enhancing community-oriented competencies such as teamwork skills and being a change agent. ^{36 , 37}

Our study has some limitations. First, as the DREEM questionnaire is a tool to assess the perception of undergrad students concerning general learning environment, it might not reflect the whole and true picture of clinical teaching environment and climate. A more clinical-specific tool may be needed. Additionally, as this survey was carried out at a certain period of the year when students were on different clerkship rotations, the results might have been different if the study had been done at the different time of academic year. Furthermore, although the DREEM questionnaire has been validated in Thai student nurses, using this tool in students in different majors and faculties may have altered the results. As this survey was conducted solely in the teaching hospitals under a special CPIRD project, it may not represent the educational environment of all medical schools in Thailand.

Perception of learning environment in clinical year students under Thailand’s CPIRD project was more positive than negative, with differences in many aspects of learning environment between sexes, years of study and size of teaching hospitals. Key areas for improvement of Thailand’s medical schools included stress management, social and academic support systems. Repeat assessment of educational environment of medical schools or departments over time is needed for monitoring changes after specific educational interventions being applied. A tool more specific to clinical year teaching may be needed.