Doctors Being Medical Teachers? Senior Doctors’ Experience of Teaching Roles at Two Hospitals in Oman

Doctors Being Medical Teachers? 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Senior Doctors’ Experience of Teaching Roles at Two Hospitals in Oman Laila Moosa Al Zidjali, Kuang-Hsu Chiang, Hamish Macleod This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6517354/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Oct, 2025 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract Background This qualitative study aims to explore senior doctors’ experiences and perceptions of their teaching roles in clinical settings at two hospitals, the Sultan Qaboos University Hospital (SQUH) and Royal Hospital of the Ministry of Health (RH), in the Sultanate of Oman. Methods In order to obtain an understanding of doctors’ clinical teaching experiences, this qualitative study uses critical realism as its methodology. In-depth semi-structured interviews were conducted with twenty-seven senior doctors at SQUH and RH. The three-layered realities of critical realism - the empirical, the actual and the real, help generate rich findings and insightful analyses. Results The study shows that in the empirical domain, senior doctors perceived their educational roles in a wide spectrum from job titles to the relational nature of their teaching. It was also found that RH doctors felt their teaching roles are less valued than SQUH doctors due to their perception that the teaching mission of their hospital is not formally recognised. Interestingly in the actual domain, there is a lack of clear definition for medical teachers in policies. To explore this further, it is found that in the real domain, although dual missions of Omani hospitals, teaching and health care, are confirmed by Omani authorities, there is seen to be a neglect of educational roles at RH. It also discovered that professional development offered by the Medical Education Unit (currently known as Medical Education and Informatics Department) for medical teachers is limited due to its exclusion of junior doctors, who do a good amount of clinical teaching. Further, it was perceived as a missed opportunity for the Ministry of Health to recognise medical teachers by not including teaching experience in the promotion criteria for all ranks of seniority. Conclusions This qualitative study offers an in-depth understanding of senior doctors’ experiences of clinical teaching at two hospitals in Oman. The lack of clear policies and formal recognition for doctors’ teaching roles, no protected time for teaching, and differential teaching rewards have made RH doctors feel their roles as medical teachers unvalued compared to SQUH doctors. For the Omani government, hospital doctors in Oman would benefit from a positive culture which values medical teaching, gives a sense of belonging for medical teachers in hospitals, offers clear definitions for their teaching roles in policies, and extends the professional development to junior doctors. The study is of value for future research investigating the balance of teaching with other duties of a doctor, and from different perspectives; for example, junior doctors, medical students and other health professionals. medical doctors’ professional development medical policies clinical training teaching senior and junior medical doctors critical realism in medical contexts Oman medical education hospital working environment teacher identity teaching experience medical doctor mentoring experience Figures Figure 1 Figure 2 Background This qualitative research aims to gain an in-depth understanding of how senior doctors perceive and experience their teaching roles within clinical settings in the Sultanate of Oman through the lens of a critical realism framework. Twenty-seven (27) senior doctors with a minimum of five years of clinical experience from two prominent hospitals, Sultan Qaboos University Hospital (SQUH) and Royal Hospital (RH), participated. SQUH is an affiliated hospital to the Sultan Qaboos University (SQU) and RH is a Ministry of Health affiliated hospital. By investigating these doctors’ perceptions, this study seeks to uncover the underlying mechanisms and structures that shape their teaching experiences. Teaching, in this study, refers to a broad range of educational activities, from structured teaching of postgraduate and undergraduate students to mentoring or role modelling for colleagues in clinical settings. A significant body of research over recent decades has explored professional development for teaching across various fields, including medicine, nursing, allied health, and vocational training (Buchel & Edwards, 2005 ; Kendrick et al., 1993 ; Martin, 1998 ; McLaughlin, 1992 ; Stalmeijer, 2015 ; Velde & Cooper, 2000 ; White et al., 2000 ). These studies highlight the evolving nature of teaching and the importance of developing teachers' skills in professional settings. In some of these settings, such as medicine, teaching and learning have recently become more formalised in nature. For example, it is seen that the curriculum has become structured based on a set of competencies prescribed by medical schools or postgraduate medical training institutions (Dacre & Fox, 2000 ; Dornan et al., 2019 ; Wagner et al., 2016 ). Some institutions support clinical doctors’ teaching by providing them with guidelines, frameworks and training opportunities (Blitz et al., 2016 ; Burgess et al., 2020 ; Daouk-Öyry et al., 2017 ; Giesler et al., 2017 ; Irby & Sullivan, 2018 ; Kilminster & Jolly, 2000 ; O’Sullivan & Irby, 2011 ; Sorinola et al., 2017 ; Steinert et al., 2010 ; Steinert & Mann, 2006 ). However, some medical teachers continue to face challenges when teaching in clinical settings (Beigzadeh et al., 2020 ; Block et al., 2015 ; Sturman et al., 2011 ). Some studies found these challenges facing medical teachers are possibly due to their perceptions of teaching, their heavy workloads with various roles, past teaching experiences and/or their personal lives (Aucott et al., 1999 ; Chung et al., 2010 ; Clark et al., 2004 ; Linzer et al., 2000 ; Papp et al., 2001 ; Steinert & Macdonald, 2015 ; Vassie et al., 2020 ). Professional Development for Medical Teachers in Oman There are currently 49 government hospitals in Muscat and the other governorates, with over 5,000 beds and numerous health centres (Ministry of Health, 2016 ). Professional development for medical doctors’ teaching is not new in Oman. The national programme of professional development for doctors was first implemented in 2002 at the Third Gulf Cooperation Council (GCC) Conference of the Faculties of Medicine and Medical Education in Muscat, Oman, followed by an agreement in 2000 at the Second GCC Conference at King Faisal University in the Kingdom of Saudi Arabia, and (GCC Conference Organizers, 2000 ). To make doctors aware of the importance of teaching, learning and assessment in both classroom and clinical settings, this programme was then developed into the Certificate Course in Health Professions Education (CHPE) by Sultan Qaboos University College of Medicine and Health Sciences (SQU-CoMHS). Over 280 faculty and affiliated faculty have attended these programmes between 2004 and 2015. Oman Medical Speciality Board (OMSB) was then set up in 2006 to develop postgraduate medical speciality education. It sets the professional and educational standards for the training and certification of medical and health professionals in Oman (Oman Medical Speciality Board, 2010 ). Although major hospitals such as SQUH and RH offer their own professional development on teaching for doctors who are involved in teaching, most of these activities are ad hoc and one-off. No comprehensive orientation is available for new doctors to teach in clinical settings, and little attention has been paid to other health team members, such as nurses, who play an important role in the day-to-day teaching of medical students, health-profession students or residents. More importantly, no one has asked doctors or affiliated health professionals about their teaching needs except through short post-workshop surveys. It is in this context that the present study explores how senior doctors experience their teaching roles in clinical settings and what this role means to them in Oman. This study aims to offer critical insights into the perceptions and experiences of senior doctors as teachers within two Omani hospitals with a hope to provide a foundation for policy development and future research. Research Methods Data were collected in 2016 using semi-structured interviews with 27 senior doctors at two governmental teaching hospitals in Oman, the Sultan Qaboos University Hospital (SQUH) and the Royal Hospital (RH) (see Supplementary File 1). Critical realism was employed as the overarching methodology to explore the complex, multi-layered experiences of doctors in their educational roles, allowing for a nuanced analysis of both observable and underlying factors influencing their teaching. Critical Realism as Methodology Although critical realism is widely applied in social sciences research, its use in medical research remains relatively new. Critical realism due to its unique view of having stratified layers of reality, has been increasingly recognised as a sound tool for obtaining profound understanding of the subject under study (Danermark et al., 2005 ; Fletcher, 2017 ; Meyer & Lunnay, 2013 ). Critical realism was first introduced by Bhaskar in the 1970s and further developed by other scholars such as Margaret Archer, Tony Lawson, Andrew Sayer, Andrew Collier and Alan Norrie (Archer, 1998 ; Bhaskar & Danermark, 2006 ; Cruickshank, 2007 ; Danermark et al., 2005 ; Porpora, 2013 ; Sayer, 1992 ). Different from realism, which argues that the world exists independently of social actors, critical realism posits that our knowledge of reality is fallible. This fallibility arises from the fact that it is socially constructed, facilitated by our perceptions and interpretations, therefore, any claims made about reality must be questioned and critiqued to reach the best understanding (Archer, 1995 , para. 177; Collier, 1994 ; Joseph, 2001 ; Scott, 2005 ). According to Bhaskar, there are three different domains of reality, namely the empirical, the actual and the real (Bhaskar, 1998 , 2008 , p. 2; Danermark et al., 2005 , pp. 20–21). These three domains are interrelated and overlap. The first domain, the empirical, is made up of the observables or experiences such as outcomes, or phenomena. It is a domain that positivists focus on and have been criticized for, as they are concerned with regularities of phenomena, reducing reality to what is observable and seeking to find “law-like connections” (Archer et al., 2016 ; Bhaskar, 1998 , pp. 139–146; Danermark et al., 2005 ; Gorski, 2013 ). The second domain, the actual, is where events and behaviours take place, independent of observation. (Bhaskar, 1998 , p. 16; Danermark et al., 2005 , p. 20). The third domain, the real, is of particular relevance here. The real is independent of our thought, awareness and even our existence as human beings (Bhaskar, 1998 , p. 16; Danermark et al., 2005 , p. 20). Bhaskar described this domain as something with various structures (or objects) which can brings about changes, phenomena or events in the actual domain and then experienced or observed in the empirical domain (Bhaskar, 2008 , pp. 35–49). Bhaskar described this domain as consisting of various structures (or objects) and generative mechanisms that have the potential to bring about changes, phenomena, or events in the actual domain, which can then be experienced or observed in the empirical domain (ibid.). Critical realists state that these structures and mechanisms are real, even if they are not tangible or visible, as they can cause events and produce “tendencies,” and it is this that we seek to understand and explain (Danermark et al., 2005 , p. 55; Houston, 2001 ). Bhaskar’s stratified domains are briefly presented in Fig. 1 . The emergence of events in the actual domain and the experiences and observations in the empirical will help to illuminate the deeply rooted mechanisms or structures in the real domain, which are often not easily observed. In this study, teaching experiences of medical doctors’ are treated as the empirical; relevant rules and regulations are seen as events in the actual domain, and finally the socio-cultural structures of the medical teaching system are treated as as the real domain (Fig. 2 ). Research Design This study collected its data through interviews, supplemented by archival data such as relevant policies and regulatory documents. In-depth open-ended interviews were conducted with twenty-seven senior doctors teaching in clinical settings at Sultan Qaboos University Hospital (SQUH) and Royal Hospital (RH). These two hospitals were selected due to their significance in medical education and their diverse medical specialties, which provided a rich context for understanding teaching practices. They are drawn from six national hospitals in Muscat Governorate in Oman. SQUH is a purpose-build university teaching hospital specifically designed for education. It has 700 beds and a staff of 3051 (Sultan Qaboos University, 2023 ). The RH is a Ministry of Health administrated hospital with 1241 beds and 3629 staff (Royal Hospital, 2024 - access date 06/10/2024). Criterion sampling was first applied to select participants who met the prespecified criteria (Table 1 ). These criteria included: (1) participants had to be practising physicians at SQUH or RH; (2) they had at least 5 years of experience teaching medical students and/or trainee doctors at different levels of their training, and (3) they were recognised as a medical teacher by either Sultan Qaboos University College of Medicine and Health Sciences (SQU-CoMHS) or Oman Medical Specialty Board (OMSB), or both (Cohen et al., 2011 , p. 143; Creswell & Creswell, 2018 , p. 224). Subsequently purposive sampling was adopted to select participants, who could offer divers and novel perspectives on the experiences of clinical teaching (Cohen et al., 2011 , p. 104; Creswell & Creswell, 2018 , p. 262). Additional Criteria included medical doctors’ gender, medical specialty (e.g., surgery, cardiology etc), clinical settings (e.g. intensive care unit versus outpatient clinic), clinical and teaching experiences, formal training in medical education (e.g. certificate, diploma, or master's degrees), ethnicity, and overseas training, which can offer different strategies for improving teaching practices. Table 1 Criteria for Selection of Participants Inclusion Criteria Exclusion Criterion Criterion Sampling Purposive Sampling Any physician with no teaching board certification 1 Practicing physician at either SQUH or RH Gender Teaching medical students and/or trainee doctors at various levels for at least 5 years Specialties (i.e. surgery versus cardiology) Recognized/certified as teachers by either SQU-CoMHS or OMSB, or both Clinical settings (i.e. intensive care unit versus outpatient clinic) Clinical experiences Teaching experiences Formal training in medical education (i.e. certificate, diploma, or master degrees) Ethnic background Overseas training The saturation principle was applied to decide the number of participants from each hospital. According to this principle, sufficient interviewees had been reached when no new information or themes emerge from the data collected (Creswell & Creswell, 2018 , p. 262; Creswell & Plano Clark, 2018, p. 270; Maxwell, 2012 , p. 95; Saunders et al., 2018 ). Initially, a manageable number of participants were chosen from both institutions to be interviewed. Data saturation was reached at SQUH with 11 participants towards the end of the planned interviews. On the other hand, additional participants from RH were recruited in order to reach data saturation. This resulted in twenty-seven participants with 11 from SQUH and 16 from RH (Table 2 ). During the interview, eight main semi-structured questions were explored, with slight variation in the order depending on the participants’ answers, which led on to include issues to be raised by later questions. NVivo 12 software was used to analyse interview data. Table 2 Demographics of Participants Gender (22) male (5) female (10) SQUH (12) RH (1) SQUH (4) RH Clinical experiences 15 years 0 1 7 19 (0) SQUH (0) RH (1) SQUH (0) RH (2) SQUH (5) RH (8) SQUH (11) RH Teaching experiences 15 years 0 13 7 7 (0) SQUH (0) RH (5) SQUH (8) RH (3) SQUH (4) RH (3) SQUH (4) RH Specialty Medical Surgical Anesthesia & Intensive Care Medicine Emergency Medicine Pediatric Radiology (3) SQUH (4) RH (2) SQUH (3) RH (0) SQUH (2) RH (3) SQUH (1) RH (3)SQUH(4) RH (0)SQUH (2) RH Studying and training country/ region Oman India & Pakistan Egypt Canada UK & EU countries Australia Under graduate medical study (8) SQUH (12) RH (2) SQUH (2) RH (1) SQUH (0) RH (0) SQUH (0) RH (0)SQUH(2) RH (0)SQUH (0) RH Postgraduate residency training (1) SQUH (3) RH (2) SQUH (2) RH (1) SQUH (0) RH (6) SQUH (6) RH (1)SQUH(4) RH (0)SQUH (0) RH Research Ethics This qualitative non-clinical study adhered to strict ethical guidelines. While the research was based in the Medical School of the University of Edinburgh, this study received scrutiny and approval from the Ethics Committee of the Moray House School of Education and Sport with which medical educational research at Edinburgh was affiliated. Additionally, ethical clearance was obtained from the Research and Ethical Committee at the Ministry of Health in Oman and the Sultan Qaboos University Medical Research and Ethics Committee, where the data collection took place. Throughout the study, participant anonymity and confidentiality were strictly maintained, and informed consent was obtained from all participants. These measures ensured the protection of participants' rights and the ethical integrity of the research process. Findings of Doctor’s Teaching Experience This section firstly presents three key findings: perceptions of their teaching roles, the importance of the teaching role recognition, and the absence of clear educational role descriptions, where the first two are in empirical domain and the third in the actual. The Empirical Perceptions of Teaching Roles Most participants, despite having over five years of clinical teaching experience, initially described their educational roles in terms of their formal job titles and institutional responsibilities, such as program director, department head, teacher, trainer, physician, or consultant. Roles such as scientific committee chair, committee member, and supervisor were also mentioned. However, few participants initially identified the relational aspects of their roles, such as being a mentor, facilitator, or role model for peers and students. These relational elements often seem to be overlooked or not formally recognized as part of their teaching role. Upon further exploration, participants described their roles as medical teachers with greater nuance, adding depth and meaning to their initial descriptions. A key dimension highlighted was the importance of relationships with colleagues, students, and junior doctors. They identified themselves as mentors to junior doctors and role models for both students and colleagues, treating students and junior doctors as future professional peers. Participants have shown altruistic behaviours, such as being kind and going beyond their ways to teach and include them in the clinical decision-making process. For example, S09 at SQUH who was actively involved in junior doctors’ training shared how he relates to residents as colleagues, working closely with them in daily clinical tasks and maximising learning opportunities in both classroom and clinical settings. [I am] heavily involved [with the postgraduate program] . . . so we design their rotations, the curriculum and their didactic teaching, so this is in terms of planning. In terms of implementation, we interact with the residents on a daily basis . . . we review the cases with them and do the teaching along with the clinical work. Also, with that, we do didactic sessions. (S09, SQUH) Several participants from both hospitals saw themselves as catalysts for change within their teaching environments. When recognizing a need for improvement, they would begin by altering their own behaviour, with the hope that colleagues and students would emulate these changes. Such changes were noted in areas like revising specialty curricula, adopting new teaching methods, and reshaping relationships with students and colleagues. Additionally, participants noted that their teaching roles evolved as they progressed in their medical careers, particularly through leadership roles assigned by the rota system. A notable distinction emerged between doctors at SQUH and RH in terms of how they perceived their roles as medical teachers. Participants from SQUH often identified themselves as teachers, viewing teaching as an integral part of their professional role. In contrast, doctors at RH were less likely to explicitly identify teaching as part of their role, reflecting differences in institutional expectations and cultural contexts. At SQUH, participants with educational administrative duties such as a director of educational programmes viewed teaching undergraduates and postgraduates as an inherent aspect of their role, requiring no further prompting. They clearly declared that they are teachers. For example, S05 (SQUH) spoke with joy and enthusiasm about his role in teaching clinical skills and other essential competencies in a clinical setting. My current roles, obviously I teach . . . In the clinical years, it’s more of teaching at the bedside as well as in seminars. I teach not only [my specialty], but we teach medicine, we teach things like quality management, patient safety and professionalism, et cetera. (S05, SQUH) Similarly, S04 (SQUH) saw his clinical teaching role as twofold: acting as an adviser who provided direction and guidance to medical students, while also serving as an organiser and a facilitator for junior doctors. To start with, my educational role for the undergraduate is, I usually give either didactic lectures or clinical bedside teaching. For the clinical bedside teaching, my role is to guide the students . . . . For postgraduate teaching, usually, we start the education with clinical bedside teaching. . . . we will go into a group discussion, and we would only be like a facilitator for them. (S04, SQUH) S11 (SQUH) perceived the training of undergraduates and postgraduates as an integral part of his professional role and responsibilities. Many SQUH doctors pointed out that teaching is expected of them as part of their roles at a university hospital like SQUH. S08 (SQUH) emphasised this by stating, “actually, in the college, we don’t have like specific, educator or teacher roles. I think it’s inherited, also part of like, you are in the college, you are a teacher, so you have to be a teacher” (S08, SQUH). For some SQUH doctors, responsibilities assigned by OMSB was considers as an added role, either it’s administrative, supervising, teaching or evaluating the junior residents in training. S11 (SQUH) highlighted the dual responsibilities he had as both a clinician and an educational programme director. He described his routine of balancing clinical duties and supervising residents: This is a University Hospital training site where we receive undergraduate and postgraduate. And in addition, I have [significant administrative oversight] for the [specialty residency] programmed of OMSB. So I supervise and interact with the resident both as an administrator and at work. So I do clinical on average two to three clinical days per week, okay. And most of the time, I have trainees working under me during the shift. So during the shift, I will supervise their cases, give them teaching, you know. And also, maybe we will go beyond that to discuss some theory, and I’ll give them evaluation as well. (S11, SQHU) In contrast, most of the RH participants, even those officially recognised by the OMSB as “official trainers”, did not explicitly identify teaching as part of their role. Instead, they referred to their educational programme director role as their primary educational role, only mentioning clinical teaching when reflecting on past educational roles, challenges or opportunities. They tended to use the word “trainer” used by OMSB, rather than “teacher”. For example, R06 from RH explained his longstanding involvement in the organization, continuing his role as a trainer while serving on various committees: I was one of the people [with longstanding organisational involvement] and now I’m . . . continue my role as a trainer, as well as a member of the Scientific Committee. And within the Scientific Committee of the Residency Program, there are subcommittees. I am a member of the Subcommittee of the Examination, as well as the Resident Progress Subcommittee. (R06, RH) Similarly, R02 (RH) emphasized his official trainer status within the residency program: I am an official trainer in [my specialty] residency program for the Oman Medical Specialty Board, and I have been doing this for the last three years. And previously, over, like, six years I was then doing clinical teaching as part of my training, being a senior resident to teach the juniors. (R02, RH) Despite the differences in roles, all participants at SQUH and RH emphasized the importance of building relationships with their students. They appreciated the opportunity to learn alongside their students and enjoyed the interactive aspect of teaching. This approach reflected their own experiences as students, where they often benefited from close interactions with their mentors. Participants viewed the clinical setting primarily as a space for students to develop their clinical skills rather than merely a venue for assessing their knowledge. As R09 expressed, “I like direct interaction rather than giving lectures [to the students and the residents]” (R09, RH). Importance of Recognising Teaching Participants at RH expressed that their teaching roles were not adequately recognized by their hospital. They highlighted a disconnect between the practical reality of their teaching responsibilities and the formal recognition on paper. Participants pointed out that although their institution (RH) functions as a teaching hospital in practice, this is not officially acknowledged. They believed this led to a lack of support from the Ministry of Health. They believed if their hospital were formally recognized as a teaching hospital, their teaching experience would improve. The perceived lack of recognition, they argued, resulted in a corresponding lack of institutional support. R02 (RH) believed that their hospital’s fundamental mission was to provide quality healthcare, a goal that has remained unchanged. But in reality, RH has also become a teaching and training site for medical students in Oman and residents from OMSB, as well as nursing and allied health students, as well as those from overseas. Participants at RH therefore felt that they are not officially recognised as teachers, even though they actively engage in teaching. [This hospital] started being like service, that was in ’86, it never aimed to be as a teaching hospital, and it’s continued from that time. So, it is definitely a teaching hospital in practice, but on paper, it’s not considered to be a teaching hospital. (R02, RH) Further, R15 (RH) emphasised that RH doctors are not recognized as medical teachers by SQU-CoMHS, which resulted in a lack of access to essential teaching resources, such as the electronic library. In comparison, affiliated doctors at SQUH have full access to these resources at Sultan Qaboos University. He said, “You’re receiving the students [at RH], you’re teaching them, you’re getting an allowance for that, once a year, but you’re not given access to their electronic library [at Medical College]” (R15, RH). A further reason for the perceived lack of recognition is disparity in teaching rewards between the two hospitals. S08 (SQUH) pointed out that all doctors at SQUH receive a monthly teaching allowance, regardless of whether they actually teach. Like you know, if you talk about the affiliated hospital, they don't get an allowance for teaching. We get an allowance for teaching. But also I think we get an allowance for teaching here, but we have also teachers whom they don't teach. (S08, SQUH) In contrast, doctors at RH who are officially recognised as teachers by SQU-CoMHS or OMSB receive only a small financial reward or a yearly teaching bonus, according to R15 and other RH participants. The disparity in rewards may contribute to RH doctors feeling less recognized compared to their SQUH counterparts. Could this difference explain why SQUH doctors are more likely to identify themselves as teachers? R03 at RH described how the differential in teaching rewards between SQUH and RH, where the former receives an allowance and the latter merely a bonus, affects how RH medical teachers feel inferior and unappreciated in comparison to their SQUH counterparts. The second [reason] is also the financing for these teachers. It is completely different from the Sultan Qaboos University, Sultan Qaboos University Hospital. For them, it is fixed, and it is as an allowance; for us, it is only just a bonus. And it is a big difference between these [at SQUH] and us, especially the tutor here. They have a sense of . . . we cannot say inferiority, but we can feel the difference. And usually, we overcome it by saying this is our country and those are our people, so it will help to teach them. . . . because this discrimination it causes some sort of sensitivity between the clinicians. (R03, RH) The Actual Absence of Clear Roles for Medical teachers Many participants expressed their concern about the lack of clarity surrounding their expected teaching roles. For this purpose, SQU-CoMHS was contacted for relevant documents, but no such documents existed, nor were they available in public domain, such as the SQUH website (access date: 06/10/2024). On the other hand, OMSB provided two relevant documents: the “ OMSB Trainer Manual”(Oman Medical Speciality Board, 2014) and “Program standards “P” and training center standards “T” for OMSB residency program Booklet” (Oman Medical Specialty Board, 2015). On examining the former (ibid., 2014), it was found that the manual is seen to offer comprehensive guidelines for trainers, rules and regulations for scientific committee members, selection criteria for committee members and trainers, trainer responsibilities, performance monitoring, and relevant OMSB policies and procedures. The latter (OMSB, 2015) highlighted the trainers’ responsibilities that are obligatory. For example: 6B.5 The Trainers must provide graded supervision appropriate to the competence and experience of the Resident and decide on awarding EPAs to the Residents as deemed appropriate. (OMSB, 2015: p. 52) The “OMSB Program and Training Standards” also specifies 15 key responsibilities for trainers, including becoming familiar with rotation objectives, supervising residents, providing continuous feedback, offering procedural opportunities, maintaining a conducive educational environment, and participating in faculty development and academic activities. Trainers are also expected to provide protected teaching time and regularly evaluate residents using OMSB evaluation forms (OMSB, 2015: 52-53). The above likely explains why some RH participants felt that being officially recognised as a trainer by OMSB helped clarify their teaching roles (R10 & R02, RH). For example, R04 (RH) found the “Training of Trainers Workshop” offered by OMSB particularly useful for understanding his teaching responsibilities (R04, RH)). Similarly, R02 (RH) perceived that his teaching role becomes more structured after he became recognized as an official OMSB trainer: I think it was most important when I got this role of, you know, trainer in OMSB, to become more structured with the commitment. . . . You know how you are doing when you get evaluated. And you know which path you are taking, what are the criteria, what are the objectives, and what I’m doing means. So it’s more structure than the previous year. (R02, RH) While joining OMSB and being recognized as official trainers made doctors more aware of certain aspects of their teaching roles, such as learning objectives, assessment and evaluation, for many participants it did not fully address the lack of clarity regarding their broader educational roles. RH participants, in particular, were inconsistent and unsure whether a written document existed that defined their educational roles for undergraduates and postgraduates. R04 (RH) felt that although some initial information was provided when becoming an official medical teacher for teaching the medical students from Sultan Qaboos University, it did not clearly specify the expected teaching role. It was only the document that described the objectives expected of students that was provided. This view was also echoed by other RH participants with R14 expressing that “we just follow the objectives that are written down” (R14, RH). S05 (SQUH) also highlighted that his teaching role was not clearly specified by SQU-CoMHS beyond the objectives set for students. While RH participants like R04 and R14 focused more on the absence of written role descriptions for both undergraduate and postgraduate teaching, SQUH participants, such as S08 and S10, emphasized that teaching is an implicit expectation within their university roles, though they similarly lacked specific, formalized role definitions. Actually, in the college, we don’t have like specific, educator or teacher roles. I think it’s inherited, also part of like, you are in the college, you are a teacher, so you have to be a teacher. (S08, SQUH). OMSB does have that, I don’t recall as specific as OMSB document. . . . [In] the college we know the goals, overall goals, but I didn’t see those specific point by point role of the trainer.” (S10, SQUH). SQUH participants tended to express a greater desire for clearly defined boundaries between their various responsibilities, reflecting the complex nature of their working environments. “Now we’re living in a place or at a time where everybody is asking a piece of you, so knowing the exact roles, the exact responsibilities, and rights, and having that in writing so that you’ve actually got something to refer to. . . . so tell me what’s your expectations so that I know if I can deliver that or not; that’s very important. (S08, SQUH)” Moreover, participants emphasised the need for educational institutions to adopt innovative and divers methods of communication with their medical teachers. S05 (SQUH) admitted that “Yes, the curriculum and the written document are there, but written documents are written documents. We read it once, and then we never look at it again” (S05, SQUH). S08 pointed out that written communication serves to build relationships and foster trust between the doctors and the educational institutions. According to R08 (SQUH) and other participants, effective communication would help align goals of all stakeholders, including teachers, hospital administration, and educational institutions. They believed that clear communication would eliminate confusion about their expected educational roles and ensure alignment with the learners’ learning objectives. S08 said: Now we’re living in a place or at a time where everybody is asking a piece of you, so knowing the exact roles, the exact responsibilities, and rights, and having that in writing so that you’ve actually got something to refer to. . . . so tell me what’s your expectations so that I know if I can deliver that or not; that’s very important. (S08, SQUH) To establish standardised roles for medical teachers nationwide, S02 (SQUH) suggested that medical teachers themselves should develop the criteria and requirements for their roles. He perceived that the absence of “critical mass” of educators and a lack of policies and guidelines, had led to inconsistent practices. “I think there are no standards now for medical teachers. If you want to talk nationwide, there is no set of standards” (S02, SQUH). S02 (SQUH) further emphasised the need for better coordination among hospitals and relevant authorities. He pointed out that medical education institutions and healthcare providers lack proper communication and alignment regarding doctors’ educational roles. He believed that those institutions must collaborate more effectively to meet their educational needs, adding, “I think if we harmonise and become one whole, it will be better” (S02, SQUH). S02 (SQUH) argued that establishing clear teaching roles for medical teachers requires input from all stakeholders. He suggested that doctors themselves should take part in developing standardised criteria for their educational roles. Such standards would enable educators to differentiate not just students at different levels of learning but also their junior colleagues and their levels of learning. What happens now is that we tend to mix our role. So we can be very harsh to the medical students who are still junior, and we take the role of teaching residents. So we don’t know in our mind and how, for example, to differentiate between a junior and a senior clerkship student and a resident R1 and the senior resident. So this role is not really clear in daily practices. (S02, SQUH) S02 (SQUH) and other participants discussed how the lack of clarity about educational roles had affected their ability to differentiate between learners at various levels. This ambiguity added another layer of complexity to their already challenging clinical environments, contributing to feelings of uncertainty in their teaching roles. Despite these challenges, it was their sense of duty they felt toward their students that helped them navigate these difficulties in clinical settings. Discussion and Interpretation of the Real Critical realists question any claim made about reality, arguing that our knowledge of reality is fallible due to two factors: it is constructed by social actors who perceive and interpret the world around them (Archer, 1995 , para. 177; Collier, 1994 , paras. 23, 25; Joseph, 2001 ; Scott, 2005 ). Despite this, they believe that there is a reality out there independent of those social actors' perceptions (Archer, 1995 , para. 177; Bhaskar, 2011 , para. 78; Collier, 1994 , para. 62; Joseph, 2001 ; Lazega, 2013 ; Scott, 2005 ). In this section, we explore how the findings from the empirical and actual domains can be attributed to structures in the real domain, focusing on the factors that shape medical doctor’s experiences and perceptions of their teaching roles in clinical settings. Teaching as One of Dual Missions for All Omani Hospitals, But RH? One important structure in the real domain is Omani medical education, which has been evolving since the 1980s with the establishment of the College of Medicine and Health Sciences at Sultan Qaboos University (SQU-CoMHS) in 1986, the first Omani teaching hospital, Sultan Qaboos University Hospital (SQUH) in 1990, and the Oman Medical Specialty Board (OMSB) in 2006. SQU-CoMHS partnered with SQUH to ensure that Omani hospitals not only provide healthcare but also offer medical education, recognizing teaching and healthcare as dual missions. Surprisingly, RH doctors did not perceive their hospital as intended to be a teaching institution. This contradicts the hospitals’ dual mission and the original goal of the Oman Project, developed in partnership with the Royal College of Physicians and Surgeons of Glasgow (RCPSG). RCPSG helped the Ministry of Health establish RH with state-of-the-art facilities for postgraduate training in the early 1980s (Hull & Geyer-Kordesch, 1999 ). Former colleagues from the first generation of doctors at RH confirmed that its teaching mission was to train medical students, a goal reflected in RH’s current vision which is to train both undergraduate and postgraduate medical and allied health students (Ministry of Health, 2024b ). The Ministry of Health (Ministry of Health, 2024a accessed date 06.10.2024) website clearly confirms that RH is a teaching hospital, not only for undergraduate medical students but also for the postgraduate residency program of OMSB. It also serves as a centre for the membership examinations for the Medical Royal Colleges of UK and Ireland and provides clinical training for the nursing and health students from affiliated institutions.. The Ministry of Health ( 2024a ) stated: The Royal Hospital is a major teaching hospital for the MD course conducted by the Sultan Qaboos University. It also serves as the main training facility for the postgraduate Residency Program of the Oman Medical Specialty Board in Medicine, Surgery, Obstetrics & Gynaecology, Child Health and Laboratory Medicine. Further, the Royal Hospital is recognized by the Royal Colleges of UK and Ireland as an official centre for the membership examinations in Medicine, Paediatrics and Surgery. Nursing and paramedical students of the Nursing Institutes in the capital area, the Institute of Health Sciences, and the Sultan Qaboos University are also provided clinical training at the Royal Hospital. (Ministry of Health, 2024a , para. 6-Access date 06-10-2024) SQU-CoMHS also identifies RH as a teaching hospital (College of Medicine and Health Sciences, 2013 , pp. XVII & 55). It recognized those who teach medical students as affiliated teachers: The [Royal Hospital] is a teaching tertiary hospital with 623 beds and 265 senior specialists and senior/consultants (70 affiliated teachers) and 1,298 nurses. Like SQUH, it receives referral cases from all over Oman. In the RH, the students rotate in medicine, child health, paediatric, surgery, Ob/Gyn, surgery, accident & emergency, radiology and anaesthesia departments. (College of Medicine and Health Sciences, 2013 , p. 55) (CoMHS, 2013: p.55) The Ministry of Health's Code of Ethics for Doctors (2007) states that, in addition to their clinical duties, doctors are responsible for education others, including patients, colleagues, and students in medical, nursing, and allied health. The code emphasizes that, as educators, physicians must: Spread health education among patients, family and the community Develop skills, attitudes and practices of a competent teacher. Teach and supervise adequately your junior colleagues, medical, nursing and paramedical students. Be honest and objective when assessing the performance of those whom you have supervised or trained. (Ministry of Health, 2007 , p. 13) It is therefore safe to say that RH is a teaching hospital. However, the question remains: why do senior doctors at RH continue to demand official recognition of their teaching roles? What leads RH participants to feel that their hospital is not truly a teaching institution, and why does this discrepancy exist? Two possible reasons explain this discrepancy. First, this is possibly because RH is administered by the Ministry of Health (MoH), which is not an educational institution. In Oman, it is only educational institutions such as College of Medicine and Health Sciences of Sultan Qaboos University (SQU-CoMHS) or OMSB, not the MoH or RH, that can certify doctors as medical teachers. Therefore, doctors at RH rely on sources or recognition at SQU-CoMHS or OMSB for their professional development as medical teachers. There is no real recognition of teaching at the institutional level within RH or by the Ministry of Health, despite existing policies. This is reflected in the differential treatment of doctors with teaching duties at RH with those at SQUH. There is a lack of protected teaching time, inadequate facilities and equipment, and insufficient rewards for their teaching efforts for doctors at RH. These factors likely contribute to the feeling that their teaching roles are undervalued by RH and Ministry of Health. Second, a sense of belonging to the institution plays a significant role. Senior doctors at SQUH perceive their hospital as a teaching institution, where teaching is an integral part of their clinical and other responsibilities. Many participants from SQUH view their roles as both clinical and educational, as they teach undergraduate and postgraduate students. S08 remarked, “I teach undergrads as part of the faculty in the College of Medicine... And also, I teach postgrads like OMSB residents” (S08, SQUH). S09 added, “I work in Sultan Qaboos University, which is a teaching hospital for both undergraduate and postgraduate” (S09, SQUH) while S11 confirmed, “this is a University Hospital training site where we receive undergraduate and postgraduate” (S11, SQUH). In contrast, RH doctors lacked this sense of belonging. Medical teachers at RH often felt undervalued and disconnected from their institution. Many believed that teaching at RH would become unsustainable over time and that the quality of teaching would deteriorate unless significant changes were made to better support RH’s medical teachers. Limitations of Professional Development for Medical Teachers Another important structure is the Medical Education Unit (MEU, currently known as Medical Education and Informatics Department) established in 2000 at the College of Medicine and Health Sciences of Sultan Qaboos University (SQU-CoMHS), which later became the Medical Education and Informatics Department. MEU offers professional development opportunities, not only for those at SQU but also for those at other affiliated teaching hospitals, and helps foster a medical education culture not only for the doctors at SOUH but also for those at RH too. However, MEU’s impact is limited. It prioritises SQUH doctors over those at RH, and its high entry requirement - requiring all applicants to be senior doctors and prior attendance at SQU-CoMHS training -creates barriers for junior doctors and other medical teachers. This produces a false impression that ‘unadmitted doctors’ are not qualified and not supposed to teach. Although SQU-CoMHS mandates that those who teach medical students must be senior specialists or consultants, in reality most senior doctors are too busy to teach. As a result, teaching responsibilities are often delegated to junior doctors. R14 and R05 at RH explained the challenge of balancing teaching with their administrative and clinical duties, which often leads to passing these tasks to subordinates. Of course, when you become at a level where your responsibilities are, sort of, becoming more and expanding, then it is not easy to keep up with your momentum, giving the sessions. So, you tend to delegate to other junior doctors or junior colleagues who can replace you. (R14, RH) While it is not unusual for junior doctors or other professionals for example nurses, or even patients to teach medical students or residents (Bradley et al., 2006 ; Riesenberg et al., 2009 ; Şükriye Abay et al., 2017 ), it is surprising that junior doctors who actually take on teaching roles are not eligible for professional development of teaching offered by MEU. This devalues the teaching contribution made by junior colleagues and sends a negative signal about teaching. R14 and other participants at RH expressed concern about assigning teaching duties to those junior doctors who haven’t received any training as a teacher. Missed Opportunity to Recognise Clinical Teaching? A mismatch exists in how clinical teaching is recognised in promotion criteria for doctors. Since Oman Medical Speciality Board (OMSB) was established in 2006 aiming to “achieve excellence in postgraduate medical education, training, assessment and accreditation” in order to “educate the next generation of leaders in medicine” (Oman Medical Speciality Board, 2010 , p. 3). An important medical bylaw passed in 2014 highlighting the value of teaching in a clinical setting by specifying teaching is a criterion for promotion to senior consultant: doctors “should be involved in teaching and educational activities at educational, training and health institutions” (Ministry of Justice and Legal Affairs, 2014 , pp. 87–88). However, the bylaw does not mention teaching as a criterion for promotion below the rank of senior consultant or once a doctor becomes a senior consultant. As a result, some doctors opt-out from their teaching duties once they are promoted to senior positions. This unfortunate omission is perceived as a ‘missed opportunity’ on the part of the Ministry of Health to promote clinical teaching for all doctors. Both R11 and R12 at RH believe that some doctors opt out of teaching because there are no consequences for not teaching, especially when teaching is perceived as an extra burden. R11 said “I have not been given a dedicated time [for teaching], so it’s understood that I will teach if I have time. If I don’t have time, I’ll not teach. So there is no compulsion on me to teach.” (R11, RH) Research Limitations One constraint of this study is about the limited access to senior doctors due to their busy and charged workload. Although the support from the directors of both hospitals was obtained, not all senior doctors were available. Those doctors who were busy or unavailable at the time was unfortunately not interviewed in this study. While there were only 5 female participants out of the overall group of 27 senior doctors, this does not under represent the female voice in this study as only 6% of senior doctors in Oman are female (Mohamed et al., 2018 ). Conclusions and Recommendations There is limited research on clinical teaching at hospitals in Oman. This qualitative study has provided rich and valuable insights into how senior doctors perceive their teaching roles in clinical settings at SQUH and RH. Twenty-seven senior doctors at the two hospitals were interviewed. Critical realism which considers the empirical, the actual and the real domains of a situation was used as the methodology. It emerged that while participants appreciated the relational aspect of their teaching roles, RH doctors felt their contributions were undervalued. Unlike their counterparts at SQUH, RH doctors were less likely to consider teaching as an integral part of their professional duties. There was a lack of protected time for teaching for RH doctors and the teaching bonus for them was simply not comparable to the teaching rewards for SQUH doctors. There is also a perceived lack of clarity surrounding the teaching roles in the actual domain despite the existence of some guidelines for medical teachers from the Oman Medical Specialty Board (OMSB). Although medical authorities recognize teaching as one of the dual missions of Omani hospitals, RH participants continued to seek formal recognition for their teaching roles. This lack of acknowledgement likely stemmed from RH's failure to adequately support its medical teachers, which has fostered a sense of exclusion and a diminished sense of belonging. The issue is further exacerbated by the restrictive criteria set by the Medical Education Unit (MEU, currently known as Medical Education and Informatics Department) at Sultan Qaboos University for professional development, which primarily benefits senior doctors while excludes many junior doctors. Moreover, Oman's 2014 medical regulation, which includes teaching as a criterion for promotion to senior positions, does not extend this requirement to ranks below or beyond senior posts. This omission has led some senior doctors to opt out of teaching altogether, while others regard it as an additional burden on top of their clinical responsibilities. Future research could expand on these findings by incorporating the perspectives of other stakeholders, including junior doctors, healthcare professionals, and medical students. Clinical teaching can be explored from other levels i.e. undergraduate, postgraduate or residency. Additionally, how to balance teaching duties with other professional responsibilities remains a central topic for many doctors. Gender disparities in Omani medical field, as in many other countries, makes it essential to explore the unique experiences of female doctors. Drawing on the findings of this study, we would like to make some recommendations for the Omani government. First, a national standard to clarify teaching roles, which is equivalent to the UK professional standards framework and standards from the Academy of Medical teachers, is needed (Academy of Medical Educators, 2014 ; Frank et al., 2015 ; The Higher Education Academy, 2011 ). Second, a national policy for allocating teaching funds and rewards, protecting teaching time, and offering access to teaching materials including libraries for all medical teachers is required. Next, it is imperative to include junior doctors in professional development for teaching, who carry out most of the clinical teaching. We also think that it is important for the Ministry of Health and its hospitals to work together to create a culture which promotes and cultivates medical teachers’ teaching identity. This will shift the perception from “some doctors who teach” to “being a doctor is being a teacher”. Medical schools certainly should take a more active role in forming doctor’s teaching identity in the early years of medical students, for example by including clinical teaching as part of the curriculum. Creating a culture of valuing medical teachers, developing a strong teaching identity, and forming a sense of belonging as being a medical teacher in a hospital are not easy. All stakeholders need to work together to offer the best quality of medical education for our future doctors in Oman. Abbreviations MEU Medical Education Unit (currently known as Medical Education and Informatics Department) RH Royal Hospital SQUH Sultan Qaboos University Hospital GCC Gulf Cooperation Council CHPE Certificate Course in Health Professions Education OMSB Oman Medical Speciality Board SQU-CoMHS Sultan Qaboos University College of Medicine and Health Sciences RCPSG Royal College of Physicians and Surgeons of Glasgow Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical standards set out in the Declaration of Helsinki. Ethical approval was obtained from multiple bodies. The study was first reviewed and approved by the Moray House School of Education and Sport Ethics Committee at the University of Edinburgh, UK, and was deemed to fall under Level 1 of the ethics screening process (i.e., low risk, not requiring formal committee review). Subsequently, ethical approval was secured from the Research and Ethical Review Committee at the Ministry of Health, Oman (Reference No. MoH/DGPS/CSR/PROPOSAL_APPROVED/38/10230), and from the Medical Research and Ethics Committee at Sultan Qaboos University (Reference No. SQU_EC 077/16). All participants were provided with a detailed participant information sheet, outlining the study purpose, voluntary nature of participation, and the measures taken to ensure confidentiality and data security. Written informed consent was obtained from all participants prior to data collection. Participants were informed that they could withdraw at any time and that their identities would remain anonymous through the use of pseudonyms. Digital recordings, consent forms, and transcripts were securely stored in password-protected files and in locked cabinets, and data handling was conducted in compliance with the UK Data Protection Act (2018) and the University of Edinburgh’s Data Protection Policy. Consent for publication All participants gave informed consent for their anonymized quotations and contributions to be published in academic outputs resulting from this research. Availability of data and materials The datasets generated and analysed during the current study are not publicly available due to confidentiality agreements with participants. However, de-identified excerpts are available from the corresponding author on reasonable request. Competing Interests The authors declare no competing interests. Funding This research was conducted as part of a doctoral thesis, which was funded by Ministry of Higher Education, Research and Innovation, Oman Authors' contributions Laila Moosa Al Zidjali is the principal author of this article, which is based on her doctoral research completed in 2022. She was responsible for the conception of the study, study design, data collection, data analysis, and manuscript preparation. Kuang-Hsu Chiang contributed to the conception, analysis, and interpretation of data and provided substantive revisions to the manuscript. Hamish Macleod contributed to the interpretation of data and provided feedback on the final draft. All authors approved the submitted version and agree to be personally accountable for their own contributions and for the integrity and accuracy of the work. Acknowledgements This article is derived from Laila Al Zidjali’s doctoral research at the University of Edinburgh, which was awarded in 2022. The authors extends their gratitude to the participants for generously sharing their experiences. The author 1 would like to express her sincere thanks to her PhD supervisors, Dr Kaung-Hsu Huang and Dr Hamish Macleod, for their guidance throughout the study. 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Supplementary Files SupplementaryFile1.docx Cite Share Download PDF Status: Published Journal Publication published 17 Oct, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 01 Jul, 2025 Reviews received at journal 30 Jun, 2025 Reviews received at journal 24 Jun, 2025 Reviewers agreed at journal 19 Jun, 2025 Reviewers agreed at journal 18 Jun, 2025 Reviewers agreed at journal 12 Jun, 2025 Reviewers invited by journal 10 Jun, 2025 Editor assigned by journal 09 Jun, 2025 Submission checks completed at journal 05 Jun, 2025 First submitted to journal 05 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6517354","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469649216,"identity":"2bed064a-8b56-4cad-8500-1d9ad291e4cb","order_by":0,"name":"Laila Moosa Al Zidjali","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIie2PsUrEQBCGJwibJl7aacRX2Gq5IiQPYjMhcNucINimWJu7RnwTW+scC6nEYBewyWJ7RSq54hA3a2OzF0vB/Yopfv6PmQEIBP4gC4juGoAlMCCAgWc2c4kfBpGyBfxWiK8mRc0oAE4Bp4B26Wkl1qo51FgsYvk60k2XP25tAnV25VWSUu3uWzxjyf4Wib9VT8+lVdrVtfIeZgsJQ8ZwTU4RjU0ipf1KatTu+InWWlcH4i+V6MyMgqXS5xtEhrK1W5pc9HNb0Ch98YDc/sKWxCsSvd1CJ35JU2nM/iMrLrfyvR+PeSE6aYaxzrzKDxI+zdI1ab4+EQ/TLH5XDgQCgf/EF0M5YkpeMQ9GAAAAAElFTkSuQmCC","orcid":"","institution":"Oman College of Health Sciences","correspondingAuthor":true,"prefix":"","firstName":"Laila","middleName":"Moosa Al","lastName":"Zidjali","suffix":""},{"id":469649217,"identity":"679b3b6a-365d-41c2-b269-c00b1d043bfa","order_by":1,"name":"Kuang-Hsu Chiang","email":"","orcid":"","institution":"University of Edinburgh","correspondingAuthor":false,"prefix":"","firstName":"Kuang-Hsu","middleName":"","lastName":"Chiang","suffix":""},{"id":469649218,"identity":"6a0dc2c2-e5c9-472f-8a20-f595fdd87d97","order_by":2,"name":"Hamish Macleod","email":"","orcid":"","institution":"University of Edinburgh","correspondingAuthor":false,"prefix":"","firstName":"Hamish","middleName":"","lastName":"Macleod","suffix":""}],"badges":[],"createdAt":"2025-04-24 05:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6517354/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6517354/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-07904-2","type":"published","date":"2025-10-17T15:57:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84439657,"identity":"30bc6090-a5ac-4c61-b1eb-144ab6e0c86b","added_by":"auto","created_at":"2025-06-12 03:33:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30554,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBhaskar’s Stratified Domains\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6517354/v1/b6680cf922822166f60422de.png"},{"id":84439506,"identity":"08350a34-2f9a-4ebc-9f7f-1dec544fc932","added_by":"auto","created_at":"2025-06-12 03:25:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":68245,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eBhaskar’s Three Domains\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6517354/v1/40e3ce0cc63416a765376111.png"},{"id":93956134,"identity":"300b743f-8981-4355-9c99-1ef107674b51","added_by":"auto","created_at":"2025-10-20 16:11:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1227068,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6517354/v1/8ab893bd-33d1-456a-834e-c7cbb81be2f3.pdf"},{"id":84439508,"identity":"0faecde6-6b23-4d1e-bad9-d517854ae6bd","added_by":"auto","created_at":"2025-06-12 03:25:07","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":16677,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6517354/v1/05744a91b905daf710451346.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Doctors Being Medical Teachers? Senior Doctors’ Experience of Teaching Roles at Two Hospitals in Oman","fulltext":[{"header":"Background","content":"\u003cp\u003eThis qualitative research aims to gain an in-depth understanding of how senior doctors perceive and experience their teaching roles within clinical settings in the Sultanate of Oman through the lens of a critical realism framework. Twenty-seven (27) senior doctors with a minimum of five years of clinical experience from two prominent hospitals, Sultan Qaboos University Hospital (SQUH) and Royal Hospital (RH), participated. SQUH is an affiliated hospital to the Sultan Qaboos University (SQU) and RH is a Ministry of Health affiliated hospital. By investigating these doctors\u0026rsquo; perceptions, this study seeks to uncover the underlying mechanisms and structures that shape their teaching experiences.\u003c/p\u003e \u003cp\u003eTeaching, in this study, refers to a broad range of educational activities, from structured teaching of postgraduate and undergraduate students to mentoring or role modelling for colleagues in clinical settings. A significant body of research over recent decades has explored professional development for teaching across various fields, including medicine, nursing, allied health, and vocational training (Buchel \u0026amp; Edwards, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Kendrick et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e1993\u003c/span\u003e; Martin, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; McLaughlin, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e1992\u003c/span\u003e; Stalmeijer, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Velde \u0026amp; Cooper, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; White et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). These studies highlight the evolving nature of teaching and the importance of developing teachers' skills in professional settings.\u003c/p\u003e \u003cp\u003eIn some of these settings, such as medicine, teaching and learning have recently become more formalised in nature. For example, it is seen that the curriculum has become structured based on a set of competencies prescribed by medical schools or postgraduate medical training institutions (Dacre \u0026amp; Fox, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Dornan et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Wagner et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Some institutions support clinical doctors\u0026rsquo; teaching by providing them with guidelines, frameworks and training opportunities (Blitz et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Burgess et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Daouk-\u0026Ouml;yry et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Giesler et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Irby \u0026amp; Sullivan, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Kilminster \u0026amp; Jolly, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; O\u0026rsquo;Sullivan \u0026amp; Irby, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Sorinola et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Steinert et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Steinert \u0026amp; Mann, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). However, some medical teachers continue to face challenges when teaching in clinical settings (Beigzadeh et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Block et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Sturman et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Some studies found these challenges facing medical teachers are possibly due to their perceptions of teaching, their heavy workloads with various roles, past teaching experiences and/or their personal lives (Aucott et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e1999\u003c/span\u003e; Chung et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Clark et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Linzer et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Papp et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Steinert \u0026amp; Macdonald, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Vassie et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eProfessional Development for Medical Teachers in Oman\u003c/h3\u003e\n\u003cp\u003eThere are currently 49 government hospitals in Muscat and the other governorates, with over 5,000 beds and numerous health centres (Ministry of Health, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Professional development for medical doctors’ teaching is not new in Oman. The national programme of professional development for doctors was first implemented in 2002 at the Third Gulf Cooperation Council (GCC) Conference of the Faculties of Medicine and Medical Education in Muscat, Oman, followed by an agreement in 2000 at the Second GCC Conference at King Faisal University in the Kingdom of Saudi Arabia, and (GCC Conference Organizers, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2000\u003c/span\u003e). To make doctors aware of the importance of teaching, learning and assessment in both classroom and clinical settings, this programme was then developed into the Certificate Course in Health Professions Education (CHPE) by Sultan Qaboos University College of Medicine and Health Sciences (SQU-CoMHS). Over 280 faculty and affiliated faculty have attended these programmes between 2004 and 2015. Oman Medical Speciality Board (OMSB) was then set up in 2006 to develop postgraduate medical speciality education. It sets the professional and educational standards for the training and certification of medical and health professionals in Oman (Oman Medical Speciality Board, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough major hospitals such as SQUH and RH offer their own professional development on teaching for doctors who are involved in teaching, most of these activities are ad hoc and one-off. No comprehensive orientation is available for new doctors to teach in clinical settings, and little attention has been paid to other health team members, such as nurses, who play an important role in the day-to-day teaching of medical students, health-profession students or residents. More importantly, no one has asked doctors or affiliated health professionals about their teaching needs except through short post-workshop surveys.\u003c/p\u003e \u003cp\u003eIt is in this context that the present study explores how senior doctors experience their teaching roles in clinical settings and what this role means to them in Oman. This study aims to offer critical insights into the perceptions and experiences of senior doctors as teachers within two Omani hospitals with a hope to provide a foundation for policy development and future research.\u003c/p\u003e "},{"header":"Research Methods","content":"\u003cp\u003eData were collected in 2016 using semi-structured interviews with 27 senior doctors at two governmental teaching hospitals in Oman, the Sultan Qaboos University Hospital (SQUH) and the Royal Hospital (RH) (see Supplementary File 1). Critical realism was employed as the overarching methodology to explore the complex, multi-layered experiences of doctors in their educational roles, allowing for a nuanced analysis of both observable and underlying factors influencing their teaching.\u003c/p\u003e\n\u003ch3\u003eCritical Realism as Methodology\u003c/h3\u003e\n\u003cp\u003e Although critical realism is widely applied in social sciences research, its use in medical research remains relatively new. Critical realism due to its unique view of having stratified layers of reality, has been increasingly recognised as a sound tool for obtaining profound understanding of the subject under study (Danermark et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Fletcher, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Meyer \u0026amp; Lunnay, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCritical realism was first introduced by Bhaskar in the 1970s and further developed by other scholars such as Margaret Archer, Tony Lawson, Andrew Sayer, Andrew Collier and Alan Norrie (Archer, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Bhaskar \u0026amp; Danermark, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Cruickshank, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Danermark et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Porpora, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Sayer, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e1992\u003c/span\u003e). Different from realism, which argues that the world exists independently of social actors, critical realism posits that our knowledge of reality is fallible. This fallibility arises from the fact that it is socially constructed, facilitated by our perceptions and interpretations, therefore, any claims made about reality must be questioned and critiqued to reach the best understanding (Archer, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1995\u003c/span\u003e, para. 177; Collier, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Joseph, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Scott, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2005\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAccording to Bhaskar, there are three different domains of reality, namely the empirical, the actual and the real (Bhaskar, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1998\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2008\u003c/span\u003e, p. 2; Danermark et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e, pp. 20\u0026ndash;21). These three domains are interrelated and overlap. The first domain, the empirical, is made up of the observables or experiences such as outcomes, or phenomena. It is a domain that positivists focus on and have been criticized for, as they are concerned with regularities of phenomena, reducing reality to what is observable and seeking to find \u0026ldquo;law-like connections\u0026rdquo; (Archer et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Bhaskar, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1998\u003c/span\u003e, pp. 139\u0026ndash;146; Danermark et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Gorski, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The second domain, the actual, is where events and behaviours take place, independent of observation. (Bhaskar, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1998\u003c/span\u003e, p. 16; Danermark et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e, p. 20).\u003c/p\u003e \u003cp\u003eThe third domain, the real, is of particular relevance here. The real is independent of our thought, awareness and even our existence as human beings (Bhaskar, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e1998\u003c/span\u003e, p. 16; Danermark et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e, p. 20). Bhaskar described this domain as something with various structures (or objects) which can brings about changes, phenomena or events in the actual domain and then experienced or observed in the empirical domain (Bhaskar, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2008\u003c/span\u003e, pp. 35\u0026ndash;49). Bhaskar described this domain as consisting of various structures (or objects) and generative mechanisms that have the potential to bring about changes, phenomena, or events in the actual domain, which can then be experienced or observed in the empirical domain (ibid.). Critical realists state that these structures and mechanisms are real, even if they are not tangible or visible, as they can cause events and produce \u0026ldquo;tendencies,\u0026rdquo; and it is this that we seek to understand and explain (Danermark et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2005\u003c/span\u003e, p. 55; Houston, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBhaskar\u0026rsquo;s stratified domains are briefly presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The emergence of events in the actual domain and the experiences and observations in the empirical will help to illuminate the deeply rooted mechanisms or structures in the real domain, which are often not easily observed. In this study, teaching experiences of medical doctors\u0026rsquo; are treated as the empirical; relevant rules and regulations are seen as events in the actual domain, and finally the socio-cultural structures of the medical teaching system are treated as as the real domain (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eResearch Design\u003c/h3\u003e\n\u003cp\u003eThis study collected its data through interviews, supplemented by archival data such as relevant policies and regulatory documents. In-depth open-ended interviews were conducted with twenty-seven senior doctors teaching in clinical settings at Sultan Qaboos University Hospital (SQUH) and Royal Hospital (RH). These two hospitals were selected due to their significance in medical education and their diverse medical specialties, which provided a rich context for understanding teaching practices. They are drawn from six national hospitals in Muscat Governorate in Oman. SQUH is a purpose-build university teaching hospital specifically designed for education. It has 700 beds and a staff of 3051 (Sultan Qaboos University, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The RH is a Ministry of Health administrated hospital with 1241 beds and 3629 staff (Royal Hospital, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2024\u003c/span\u003e - access date 06/10/2024).\u003c/p\u003e \u003cp\u003eCriterion sampling was first applied to select participants who met the prespecified criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). These criteria included: (1) participants had to be practising physicians at SQUH or RH; (2) they had at least 5 years of experience teaching medical students and/or trainee doctors at different levels of their training, and (3) they were recognised as a medical teacher by either Sultan Qaboos University College of Medicine and Health Sciences (SQU-CoMHS) or Oman Medical Specialty Board (OMSB), or both (Cohen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2011\u003c/span\u003e, p. 143; Creswell \u0026amp; Creswell, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, p. 224).\u003c/p\u003e \u003cp\u003eSubsequently purposive sampling was adopted to select participants, who could offer divers and novel perspectives on the experiences of clinical teaching (Cohen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2011\u003c/span\u003e, p. 104; Creswell \u0026amp; Creswell, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, p. 262). Additional Criteria included medical doctors\u0026rsquo; gender, medical specialty (e.g., surgery, cardiology etc), clinical settings (e.g. intensive care unit versus outpatient clinic), clinical and teaching experiences, formal training in medical education (e.g. certificate, diploma, or master's degrees), ethnicity, and overseas training, which can offer different strategies for improving teaching practices.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCriteria for Selection of Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eInclusion Criteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExclusion Criterion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCriterion Sampling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePurposive Sampling\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAny physician with no teaching board certification\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePracticing physician at either SQUH or RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeaching medical students and/or trainee doctors at various levels for at least 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSpecialties\u003c/p\u003e \u003cp\u003e(i.e. surgery versus cardiology)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecognized/certified as teachers by either SQU-CoMHS or OMSB, or both\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical settings\u003c/p\u003e \u003cp\u003e(i.e. intensive care unit versus outpatient clinic)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTeaching experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFormal training in medical education\u003c/p\u003e \u003cp\u003e(i.e. certificate, diploma, or master degrees)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEthnic background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverseas training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe saturation principle was applied to decide the number of participants from each hospital. According to this principle, sufficient interviewees had been reached when no new information or themes emerge from the data collected (Creswell \u0026amp; Creswell, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e, p. 262; Creswell \u0026amp; Plano Clark, 2018, p. 270; Maxwell, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2012\u003c/span\u003e, p. 95; Saunders et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Initially, a manageable number of participants were chosen from both institutions to be interviewed. Data saturation was reached at SQUH with 11 participants towards the end of the planned interviews. On the other hand, additional participants from RH were recruited in order to reach data saturation. This resulted in twenty-seven participants with 11 from SQUH and 16 from RH (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). During the interview, eight main semi-structured questions were explored, with slight variation in the order depending on the participants\u0026rsquo; answers, which led on to include issues to be raised by later questions. NVivo 12 software was used to analyse interview data.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics of Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(22)\u003c/p\u003e \u003cp\u003emale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5)\u003c/p\u003e \u003cp\u003efemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(10) SQUH\u003c/p\u003e \u003cp\u003e(12) RH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1) SQUH\u003c/p\u003e \u003cp\u003e(4) RH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eClinical\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eexperiences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;5 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5\u0026ndash;10\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eyears\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e11\u0026ndash;15\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eyears\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;15 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(0) SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1) SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(2) SQUH\u003c/p\u003e \u003cp\u003e(5) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(8) SQUH\u003c/p\u003e \u003cp\u003e(11) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eTeaching\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eexperiences\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;5 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e5\u0026ndash;10\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eyears\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e11\u0026ndash;15\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eyears\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;15 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e13\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(0) SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5) SQUH\u003c/p\u003e \u003cp\u003e(8) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3) SQUH\u003c/p\u003e \u003cp\u003e(4) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3) SQUH\u003c/p\u003e \u003cp\u003e(4) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSpecialty\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMedical\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eSurgical\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eAnesthesia \u0026amp; Intensive\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eCare\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eMedicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eEmergency Medicine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003ePediatric\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eRadiology\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(3) SQUH\u003c/p\u003e \u003cp\u003e(4) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2) SQUH\u003c/p\u003e \u003cp\u003e(3) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(0) SQUH\u003c/p\u003e \u003cp\u003e(2) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(3) SQUH\u003c/p\u003e \u003cp\u003e(1) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(3)SQUH(4) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0)SQUH\u003c/p\u003e \u003cp\u003e(2) RH\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStudying and\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003etraining\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ecountry/\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eregion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eOman\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIndia \u0026amp; Pakistan\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eEgypt\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eCanada\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eUK \u0026amp; EU\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ecountries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eAustralia\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder\u003c/p\u003e \u003cp\u003egraduate\u003c/p\u003e \u003cp\u003emedical study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(8) SQUH\u003c/p\u003e \u003cp\u003e(12) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2) SQUH\u003c/p\u003e \u003cp\u003e(2) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(1) SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(0) SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(0)SQUH(2) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0)SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003cp\u003eresidency\u003c/p\u003e \u003cp\u003etraining\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(1) SQUH\u003c/p\u003e \u003cp\u003e(3) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(2) SQUH\u003c/p\u003e \u003cp\u003e(2) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(1) SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(6) SQUH\u003c/p\u003e \u003cp\u003e(6) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(1)SQUH(4) RH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0)SQUH\u003c/p\u003e \u003cp\u003e(0) RH\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eResearch Ethics\u003c/h3\u003e\n\u003cp\u003e This qualitative non-clinical study adhered to strict ethical guidelines. While the research was based in the Medical School of the University of Edinburgh, this study received scrutiny and approval from the Ethics Committee of the Moray House School of Education and Sport with which medical educational research at Edinburgh was affiliated. Additionally, ethical clearance was obtained from the Research and Ethical Committee at the Ministry of Health in Oman and the Sultan Qaboos University Medical Research and Ethics Committee, where the data collection took place. Throughout the study, participant anonymity and confidentiality were strictly maintained, and informed consent was obtained from all participants. These measures ensured the protection of participants' rights and the ethical integrity of the research process.\u003c/p\u003e"},{"header":"Findings of Doctor’s Teaching Experience","content":"\u003cp\u003eThis section firstly presents three key findings: perceptions of their teaching roles, the importance of the teaching role recognition, and the absence of clear educational role descriptions, where the first two are in empirical domain and the third in the actual.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Empirical\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePerceptions of Teaching Roles\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants, despite having over five years of clinical teaching experience, initially described their educational roles in terms of their formal job titles and institutional responsibilities, such as program director, department head, teacher, trainer, physician, or consultant. Roles such as scientific committee chair, committee member, and supervisor were also mentioned. However, few participants initially identified the relational aspects of their roles, such as being a mentor, facilitator, or role model for peers and students. These relational elements often seem to be overlooked or not formally recognized as part of their teaching role.\u003c/p\u003e\n\u003cp\u003eUpon further exploration, participants described their roles as medical teachers with greater nuance, adding depth and meaning to their initial descriptions. A key dimension highlighted was the importance of relationships with colleagues, students, and junior doctors. They identified themselves as mentors to junior doctors and role models for both students and colleagues, treating students and junior doctors as future professional peers. Participants have shown altruistic behaviours, such as being kind and going beyond their ways to teach and include them in the clinical decision-making process. For example, S09 at SQUH who was actively involved in junior doctors’ training shared how he relates to residents as colleagues, working closely with them in daily clinical tasks and\u0026nbsp;maximising learning opportunities in both classroom and clinical settings.\u003c/p\u003e\n\u003cp\u003e[I am] heavily involved [with the postgraduate program] . . . so we design their rotations, the curriculum and their didactic teaching, so this is in terms of planning. In terms of implementation, we interact with the residents on a daily basis . . . we review the cases with them and do the teaching along with the clinical work. Also, with that, we do didactic sessions.\u003c/p\u003e\n\u003cp\u003e(S09, SQUH)\u003c/p\u003e\n\u003cp\u003eSeveral participants from both hospitals saw themselves as catalysts for change within their teaching environments. When recognizing a need for improvement, they would begin by altering their own behaviour, with the hope that colleagues and students would emulate these changes. Such changes were noted in areas like revising specialty curricula, adopting new teaching methods, and reshaping relationships with students and colleagues. Additionally, participants noted that their teaching roles evolved as they progressed in their medical careers, particularly through leadership roles assigned by the rota system.\u003c/p\u003e\n\u003cp\u003eA notable distinction emerged between doctors at SQUH and RH in terms of how they perceived their roles as medical teachers. Participants from SQUH often identified themselves as teachers, viewing teaching as an integral part of their professional role. In contrast, doctors at RH were less likely to explicitly identify teaching as part of their role, reflecting differences in institutional expectations and cultural contexts.\u003c/p\u003e\n\u003cp\u003eAt SQUH, participants with educational administrative duties such as a director of educational programmes viewed teaching undergraduates and postgraduates as an inherent aspect of their role, requiring no further prompting. They clearly declared that they are teachers. For example, S05 (SQUH) spoke with joy and enthusiasm about his role in teaching clinical skills and other essential competencies in a clinical setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMy current roles, obviously I teach . . . In the clinical years, it’s more of teaching at the bedside as well as in seminars. I teach not only [my specialty], but we teach medicine, we teach things like quality management, patient safety and professionalism, et cetera.\u003c/p\u003e\n\u003cp\u003e(S05, SQUH)\u003c/p\u003e\n\u003cp\u003eSimilarly, S04 (SQUH) saw his clinical teaching role as twofold: acting as an adviser who provided direction and guidance to medical students, while also serving as an organiser and a facilitator for junior doctors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo start with, my educational role for the undergraduate is, I usually give either didactic lectures or clinical bedside teaching. For the clinical bedside teaching, my role is to guide the students . . . . For postgraduate teaching, usually, we start the education with clinical bedside teaching. . . . we will go into a group discussion, and we would only be like a facilitator for them.\u003c/p\u003e\n\u003cp\u003e(S04, SQUH)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eS11 (SQUH) perceived the training of undergraduates and postgraduates as an integral part of his professional role and responsibilities. Many SQUH doctors pointed out that teaching is expected of them as part of their roles at a university hospital like SQUH. S08 (SQUH)\u0026nbsp;emphasised this by stating, “actually, in the college, we don’t have like specific, educator or teacher roles. I think it’s inherited, also part of like, you are in the college, you are a teacher, so you have to be a teacher” (S08, SQUH). For some SQUH doctors, responsibilities assigned by OMSB was considers as an added role, either it’s administrative, supervising, teaching or evaluating the junior residents in training.\u003c/p\u003e\n\u003cp\u003eS11 (SQUH) highlighted the dual responsibilities he\u0026nbsp;had as both a clinician and an educational programme director. He described his routine of balancing clinical duties and supervising residents:\u003c/p\u003e\n\u003cp\u003eThis is a University Hospital training site where we receive undergraduate and postgraduate. And in addition, I have [significant administrative oversight] for the [specialty residency] programmed of OMSB. So I supervise and interact with the resident both as an administrator and at work. So I do clinical on average two to three clinical days per week, okay. And most of the time, I have trainees working under me during the shift. So during the shift, I will supervise their cases, give them teaching, you know. And also, maybe we will go beyond that to discuss some theory, and I’ll give them evaluation as well.\u003c/p\u003e\n\u003cp\u003e(S11, SQHU)\u003c/p\u003e\n\u003cp\u003eIn contrast, most of the RH participants,\u0026nbsp;even those officially recognised by the OMSB as “official trainers”, did not explicitly identify teaching as part of their role. Instead, they referred to their educational programme director role as their primary educational role, only mentioning clinical teaching when reflecting on past educational roles, challenges or opportunities. They tended to use the word “trainer” used by OMSB, rather than “teacher”. For example, R06 from RH explained his longstanding involvement in the organization, continuing his role as a trainer while serving on various committees:\u003c/p\u003e\n\u003cp\u003eI was one of the people [with longstanding organisational involvement] and now I’m . . . continue my role as a trainer, as well as a member of the Scientific Committee. And within the Scientific Committee of the Residency Program, there are subcommittees. I am a member of the Subcommittee of the Examination, as well as the Resident Progress Subcommittee.\u003c/p\u003e\n\u003cp\u003e(R06, RH)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSimilarly, R02 (RH) emphasized his official trainer status within the residency program: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI am an official trainer in [my specialty] residency program for the Oman Medical Specialty Board, and I have been doing this for the last three years. And previously, over, like, six years I was then doing clinical teaching as part of my training, being a senior resident to teach the juniors.\u003c/p\u003e\n\u003cp\u003e(R02, RH)\u003c/p\u003e\n\u003cp\u003eDespite the differences in roles, all participants at SQUH and RH emphasized the importance of building relationships with their students. They appreciated the opportunity to learn alongside their students and enjoyed the interactive aspect of teaching. This approach reflected their own experiences as students, where they often benefited from close interactions with their mentors. Participants viewed the clinical setting primarily as a space for students to develop their clinical skills rather than merely a venue for assessing their knowledge. As R09 expressed, “I like direct interaction rather than giving lectures [to the students and the residents]” (R09, RH).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eImportance\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eof\u0026nbsp;Recognising\u0026nbsp;Teaching\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants at RH expressed that their teaching roles were not adequately recognized by their hospital.\u0026nbsp;They highlighted a disconnect between the practical reality of their teaching responsibilities and the formal recognition on paper. Participants pointed out that although their institution (RH) functions as a teaching hospital in practice, this is not officially acknowledged. They believed this led to a lack of support from the Ministry of Health. They believed if their hospital were formally recognized as a teaching hospital, their teaching experience would improve. The perceived lack of recognition, they argued, resulted in a corresponding lack of institutional support.\u003c/p\u003e\n\u003cp\u003eR02 (RH) believed that their hospital’s fundamental mission was to provide quality healthcare, a goal that has remained unchanged. But in reality, RH has also become a teaching and training site for medical students in Oman and residents from OMSB, as well as nursing and allied health students, as well as those from overseas. Participants at RH therefore felt that they are not officially recognised as teachers, even though they actively engage in teaching.\u003c/p\u003e\n\u003cp\u003e[This hospital] started being like service, that was in ’86, it never aimed to be as a teaching hospital, and it’s continued from that time. So, it is definitely a teaching hospital in practice, but on paper, it’s not considered to be a teaching hospital.\u003c/p\u003e\n\u003cp\u003e(R02, RH)\u003c/p\u003e\n\u003cp\u003eFurther, R15 (RH)\u0026nbsp;emphasised that RH doctors are not recognized as medical teachers by SQU-CoMHS, which resulted in a lack of access to essential teaching resources, such as the electronic library. In comparison, affiliated doctors at SQUH have full access to these resources at Sultan Qaboos University. He said, “You’re receiving the students [at RH], you’re teaching them, you’re getting an allowance for that, once a year, but you’re not given access to their electronic library [at Medical College]” (R15, RH).\u003c/p\u003e\n\u003cp\u003eA further reason for the perceived lack of recognition is disparity in teaching rewards between the two hospitals. S08 (SQUH) pointed out that all doctors at SQUH receive a monthly teaching allowance, regardless of whether they actually teach.\u003c/p\u003e\n\u003cp\u003eLike you know, if you talk about the affiliated hospital, they don't get an allowance for teaching. We get an allowance for teaching. But also I think we get an allowance for teaching here, but we have also teachers whom they don't teach.\u003c/p\u003e\n\u003cp\u003e(S08, SQUH)\u003c/p\u003e\n\u003cp\u003eIn contrast, doctors at RH who are officially recognised\u0026nbsp;as teachers by SQU-CoMHS or OMSB receive only a small financial reward or a yearly teaching bonus, according to R15 and other RH participants. The disparity in rewards may contribute to RH doctors feeling less recognized compared to their SQUH counterparts. Could this difference explain why SQUH doctors are more likely to identify themselves as teachers?\u003c/p\u003e\n\u003cp\u003eR03 at RH described how the differential in teaching rewards between SQUH and RH, where the former receives an allowance and the latter merely a bonus, affects how RH medical teachers feel inferior and unappreciated in comparison to their SQUH counterparts.\u003c/p\u003e\n\u003cp\u003eThe second [reason] is also the financing for these teachers. It is completely different from the Sultan Qaboos University, Sultan Qaboos University Hospital. For them, it is fixed, and it is as an allowance; for us, it is only just a bonus. And it is a big difference between these [at SQUH] and us, especially the tutor here. They have a sense of . . . we cannot say inferiority, but we can feel the difference. And usually, we overcome it by saying this is our country and those are our people, so it will help to teach them. . . . because this discrimination it causes some sort of sensitivity between the clinicians.\u003c/p\u003e\n\u003cp\u003e(R03, RH)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Actual\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbsence of Clear Roles for Medical teachers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany participants expressed their concern about the lack of clarity surrounding their expected teaching roles. For this purpose, SQU-CoMHS was contacted for relevant documents, but no such documents existed, nor were they available in public domain, such as the SQUH website (access date: 06/10/2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn the other hand, OMSB provided two relevant documents: the\u003cstrong\u003e\u0026nbsp;“\u003c/strong\u003eOMSB Trainer Manual”(Oman Medical Speciality Board, 2014) and “Program standards “P” and training center standards “T” for OMSB residency program Booklet” (Oman Medical Specialty Board, 2015). On examining the former (ibid., 2014), it was found that the manual is seen to offer comprehensive guidelines for trainers, rules and regulations for scientific committee members, selection criteria for committee members and trainers, trainer responsibilities, performance monitoring, and relevant OMSB policies and procedures. The latter (OMSB, 2015)\u0026nbsp;highlighted the trainers’ responsibilities that are obligatory. For example:\u003c/p\u003e\n\u003cp\u003e6B.5 The Trainers must provide graded supervision appropriate to the competence and experience of the Resident and decide on awarding EPAs to the Residents as deemed appropriate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(OMSB, 2015: p. 52)\u003c/p\u003e\n\u003cp\u003eThe “OMSB Program and Training Standards” also specifies 15 key responsibilities for trainers, including becoming familiar with rotation objectives, supervising residents, providing continuous feedback, offering procedural opportunities, maintaining a conducive educational environment, and participating in faculty development and academic activities. Trainers are also expected to provide protected teaching time and regularly evaluate residents using OMSB evaluation forms\u0026nbsp;(OMSB, 2015: 52-53).\u003c/p\u003e\n\u003cp\u003eThe above likely explains why some RH participants felt that being officially recognised as \u0026nbsp;a trainer by OMSB helped clarify their teaching roles (R10 \u0026amp; R02, RH). For example, R04 (RH) found the “Training of Trainers Workshop” offered by OMSB particularly useful for understanding his teaching responsibilities (R04, RH)). Similarly, R02 (RH) perceived that his teaching role becomes more structured after he became recognized as an official OMSB trainer:\u003c/p\u003e\n\u003cp\u003eI think it was most important when I got this role of, you know, trainer in OMSB, to become more structured with the commitment. . . . You know how you are doing when you get evaluated. And you know which path you are taking, what are the criteria, what are the objectives, and what I’m doing means. So it’s more structure than the previous year.\u003c/p\u003e\n\u003cp\u003e(R02, RH)\u003c/p\u003e\n\u003cp\u003eWhile joining OMSB and being recognized as official trainers made doctors more aware of certain aspects of their teaching roles, such as learning objectives, assessment and evaluation, for many participants it did not fully address the lack of clarity regarding their broader educational roles. RH participants, in particular, were inconsistent and unsure whether a written document existed that defined their educational roles for undergraduates and postgraduates. R04 (RH) felt that although some initial information was provided when becoming an official medical teacher for teaching the medical students from Sultan Qaboos University, it did not clearly specify the expected teaching role. It was only the document that described the objectives expected of students\u0026nbsp;that was provided. This view was also echoed by other RH participants with R14 expressing that “we just follow the objectives that are written down”\u0026nbsp;(R14, RH). S05 (SQUH) also highlighted that his teaching role was not clearly specified by SQU-CoMHS beyond the objectives set for students.\u003c/p\u003e\n\u003cp\u003eWhile RH participants like R04 and R14 focused more on the absence of written role descriptions for both undergraduate and postgraduate teaching, SQUH participants, such as S08 and S10, emphasized that teaching is an implicit expectation within their university roles, though they similarly lacked specific, formalized role definitions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eActually, in the college, we don’t have like specific, educator or teacher roles. I think it’s inherited, also part of like, you are in the college, you are a teacher, so you have to be a teacher. (S08, SQUH).\u003c/p\u003e\n\u003cp\u003eOMSB does have that, I don’t recall as specific as OMSB document. . . . [In] the college we know the goals, overall goals, but I didn’t see those specific point by point role of the trainer.” (S10, SQUH).\u003c/p\u003e\n\u003cp\u003eSQUH participants tended to express a greater desire for clearly defined boundaries between their various responsibilities, reflecting the complex nature of their working environments.\u003c/p\u003e\n\u003cp\u003e“Now we’re living in a place or at a time where everybody is asking a piece of you, so knowing the exact roles, the exact responsibilities, and rights, and having that in writing so that you’ve actually got something to refer to. . . . so tell me what’s your expectations so that I know if I can deliver that or not; that’s very important. (S08, SQUH)”\u003c/p\u003e\n\u003cp\u003eMoreover, participants\u0026nbsp;emphasised the need for educational institutions to adopt innovative and divers methods of communication with their medical teachers. S05 (SQUH) admitted that “Yes, the curriculum and the written document are there, but written documents are written documents. We read it once, and then we never look at it again” (S05, SQUH). S08 pointed out that written communication serves to build relationships and foster trust between the doctors and the educational institutions. According to R08 (SQUH) and other participants, effective communication would help align goals of all stakeholders, including teachers, hospital administration, and educational institutions. They believed that clear communication would eliminate confusion about their expected educational roles and ensure alignment with the learners’ learning objectives. S08 said:\u003c/p\u003e\n\u003cp\u003eNow we’re living in a place or at a time where everybody is asking a piece of you, so knowing the exact roles, the exact responsibilities, and rights, and having that in writing so that you’ve actually got something to refer to. . . . so tell me what’s your expectations so that I know if I can deliver that or not; that’s very important.\u003c/p\u003e\n\u003cp\u003e(S08, SQUH)\u003c/p\u003e\n\u003cp\u003eTo establish\u0026nbsp;standardised roles for medical teachers nationwide, S02 (SQUH) suggested that medical teachers themselves should develop the criteria and requirements for their roles. He perceived that the absence of “critical mass” of educators and a lack of policies and guidelines, had led to inconsistent practices. “I think there are no standards now for medical teachers. If you want to talk nationwide, there is no set of standards” (S02, SQUH).\u003c/p\u003e\n\u003cp\u003eS02 (SQUH) further\u0026nbsp;emphasised the need for better coordination among hospitals and relevant authorities. He pointed out that medical education institutions and healthcare providers lack proper communication and alignment regarding doctors’ educational roles. He believed that those institutions must collaborate more effectively to meet their educational needs, adding, “I think if we harmonise and become one whole, it will be better” (S02, SQUH).\u003c/p\u003e\n\u003cp\u003eS02 (SQUH) argued that establishing clear teaching roles for medical teachers requires input from all stakeholders. He suggested that doctors themselves should take part in developing\u0026nbsp;standardised criteria for their educational roles. Such standards would enable educators to differentiate not just students at different levels of learning but also their junior colleagues and their levels of learning.\u003c/p\u003e\n\u003cp\u003eWhat happens now is that we tend to mix our role. So we can be very harsh to the medical students who are still junior, and we take the role of teaching residents. So we don’t know in our mind and how, for example, to differentiate between a junior and a senior clerkship student and a resident R1 and the senior resident. So this role is not really clear in daily practices.\u003c/p\u003e\n\u003cp\u003e(S02, SQUH)\u003c/p\u003e\n\u003cp\u003eS02 (SQUH) and other participants discussed how the lack of clarity about educational roles had affected their ability to differentiate between learners at various levels. This ambiguity added another layer of complexity to their already challenging clinical environments, contributing to feelings of uncertainty in their teaching roles. Despite these challenges, it was their sense of duty they felt toward their students that helped them navigate these difficulties in clinical settings.\u003c/p\u003e"},{"header":"Discussion and Interpretation of the Real","content":"\u003cp\u003eCritical realists question any claim made about reality, arguing that our knowledge of reality is fallible due to two factors: it is constructed by social actors who perceive and interpret the world around them (Archer, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1995\u003c/span\u003e, para. 177; Collier, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1994\u003c/span\u003e, paras. 23, 25; Joseph, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Scott, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Despite this, they believe that there is a reality out there independent of those social actors' perceptions (Archer, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1995\u003c/span\u003e, para. 177; Bhaskar, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2011\u003c/span\u003e, para. 78; Collier, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1994\u003c/span\u003e, para. 62; Joseph, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Lazega, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Scott, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). In this section, we explore how the findings from the empirical and actual domains can be attributed to structures in the real domain, focusing on the factors that shape medical doctor’s experiences and perceptions of their teaching roles in clinical settings.\u003c/p\u003e\u003ch2\u003eTeaching as One of Dual Missions for All Omani Hospitals, But RH?\u003c/h2\u003e\u003cp\u003e One important structure in the real domain is Omani medical education, which has been evolving since the 1980s with the establishment of the College of Medicine and Health Sciences at Sultan Qaboos University (SQU-CoMHS) in 1986, the first Omani teaching hospital, Sultan Qaboos University Hospital (SQUH) in 1990, and the Oman Medical Specialty Board (OMSB) in 2006. SQU-CoMHS partnered with SQUH to ensure that Omani hospitals not only provide healthcare but also offer medical education, recognizing teaching and healthcare as dual missions.\u003c/p\u003e\u003cp\u003eSurprisingly, RH doctors did not perceive their hospital as intended to be a teaching institution. This contradicts the hospitals’ dual mission and the original goal of the Oman Project, developed in partnership with the Royal College of Physicians and Surgeons of Glasgow (RCPSG). RCPSG helped the Ministry of Health establish RH with state-of-the-art facilities for postgraduate training in the early 1980s (Hull \u0026amp; Geyer-Kordesch, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e1999\u003c/span\u003e). Former colleagues from the first generation of doctors at RH confirmed that its teaching mission was to train medical students, a goal reflected in RH’s current vision which is to train both undergraduate and postgraduate medical and allied health students (Ministry of Health, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe Ministry of Health (Ministry of Health, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e accessed date 06.10.2024) website clearly confirms that RH is a teaching hospital, not only for undergraduate medical students but also for the postgraduate residency program of OMSB. It also serves as a centre for the membership examinations for the Medical Royal Colleges of UK and Ireland and provides clinical training for the nursing and health students from affiliated institutions.. The Ministry of Health (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e) stated:\u003c/p\u003e\u003cp\u003eThe Royal Hospital is a major teaching hospital for the MD course conducted by the Sultan Qaboos University. It also serves as the main training facility for the postgraduate Residency Program of the Oman Medical Specialty Board in Medicine, Surgery, Obstetrics \u0026amp; Gynaecology, Child Health and Laboratory Medicine. Further, the Royal Hospital is recognized by the Royal Colleges of UK and Ireland as an official centre for the membership examinations in Medicine, Paediatrics and Surgery. Nursing and paramedical students of the Nursing Institutes in the capital area, the Institute of Health Sciences, and the Sultan Qaboos University are also provided clinical training at the Royal Hospital.\u003c/p\u003e\u003cp\u003e(Ministry of Health, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e, para. 6-Access date 06-10-2024)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSQU-CoMHS also identifies RH as a teaching hospital (College of Medicine and Health Sciences, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, pp. XVII \u0026amp; 55). It recognized those who teach medical students as affiliated teachers:\u003c/p\u003e\u003cp\u003eThe [Royal Hospital] is a teaching tertiary hospital with 623 beds and 265 senior specialists and senior/consultants (70 affiliated teachers) and 1,298 nurses. Like SQUH, it receives referral cases from all over Oman. In the RH, the students rotate in medicine, child health, paediatric, surgery, Ob/Gyn, surgery, accident \u0026amp; emergency, radiology and anaesthesia departments.\u003c/p\u003e\u003cp\u003e(College of Medicine and Health Sciences, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2013\u003c/span\u003e, p. 55) (CoMHS, 2013: p.55)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe Ministry of Health's Code of Ethics for Doctors (2007) states that, in addition to their clinical duties, doctors are responsible for education others, including patients, colleagues, and students in medical, nursing, and allied health. The code emphasizes that, as educators, physicians must:\u003c/p\u003e\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eSpread health education among patients, family and the community\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDevelop skills, attitudes and practices of a competent teacher.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTeach and supervise adequately your junior colleagues, medical, nursing and paramedical students.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBe honest and objective when assessing the performance of those whom you have supervised or trained.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003e(Ministry of Health, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2007\u003c/span\u003e, p. 13)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIt is therefore safe to say that RH is a teaching hospital. However, the question remains: why do senior doctors at RH continue to demand official recognition of their teaching roles? What leads RH participants to feel that their hospital is not truly a teaching institution, and why does this discrepancy exist?\u003c/p\u003e\u003cp\u003eTwo possible reasons explain this discrepancy. First, this is possibly because RH is administered by the Ministry of Health (MoH), which is not an educational institution. In Oman, it is only educational institutions such as College of Medicine and Health Sciences of Sultan Qaboos University (SQU-CoMHS) or OMSB, not the MoH or RH, that can certify doctors as medical teachers. Therefore, doctors at RH rely on sources or recognition at SQU-CoMHS or OMSB for their professional development as medical teachers. There is no real recognition of teaching at the institutional level within RH or by the Ministry of Health, despite existing policies. This is reflected in the differential treatment of doctors with teaching duties at RH with those at SQUH. There is a lack of protected teaching time, inadequate facilities and equipment, and insufficient rewards for their teaching efforts for doctors at RH. These factors likely contribute to the feeling that their teaching roles are undervalued by RH and Ministry of Health.\u003c/p\u003e\u003cp\u003eSecond, a sense of belonging to the institution plays a significant role. Senior doctors at SQUH perceive their hospital as a teaching institution, where teaching is an integral part of their clinical and other responsibilities. Many participants from SQUH view their roles as both clinical and educational, as they teach undergraduate and postgraduate students. S08 remarked, “I teach undergrads as part of the faculty in the College of Medicine... And also, I teach postgrads like OMSB residents” (S08, SQUH). S09 added, “I work in Sultan Qaboos University, which is a teaching hospital for both undergraduate and postgraduate” (S09, SQUH) while S11 confirmed, “this is a University Hospital training site where we receive undergraduate and postgraduate” (S11, SQUH).\u003c/p\u003e\u003cp\u003eIn contrast, RH doctors lacked this sense of belonging. Medical teachers at RH often felt undervalued and disconnected from their institution. Many believed that teaching at RH would become unsustainable over time and that the quality of teaching would deteriorate unless significant changes were made to better support RH’s medical teachers.\u003c/p\u003e\u003ch2\u003eLimitations of Professional Development for Medical Teachers\u003c/h2\u003e\u003cp\u003eAnother important structure is the Medical Education Unit (MEU, currently known as Medical Education and Informatics Department) established in 2000 at the College of Medicine and Health Sciences of Sultan Qaboos University (SQU-CoMHS), which later became the Medical Education and Informatics Department. MEU offers professional development opportunities, not only for those at SQU but also for those at other affiliated teaching hospitals, and helps foster a medical education culture not only for the doctors at SOUH but also for those at RH too. However, MEU’s impact is limited. It prioritises SQUH doctors over those at RH, and its high entry requirement - requiring all applicants to be senior doctors and prior attendance at SQU-CoMHS training -creates barriers for junior doctors and other medical teachers. This produces a false impression that ‘unadmitted doctors’ are not qualified and not supposed to teach.\u003c/p\u003e\u003cp\u003eAlthough SQU-CoMHS mandates that those who teach medical students must be senior specialists or consultants, in reality most senior doctors are too busy to teach. As a result, teaching responsibilities are often delegated to junior doctors. R14 and R05 at RH explained the challenge of balancing teaching with their administrative and clinical duties, which often leads to passing these tasks to subordinates.\u003c/p\u003e\u003cp\u003eOf course, when you become at a level where your responsibilities are, sort of, becoming more and expanding, then it is not easy to keep up with your momentum, giving the sessions. So, you tend to delegate to other junior doctors or junior colleagues who can replace you.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003ch2\u003e(R14, RH)\u003c/h2\u003e\u003cp\u003eWhile it is not unusual for junior doctors or other professionals for example nurses, or even patients to teach medical students or residents (Bradley et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Riesenberg et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; Şükriye Abay et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), it is surprising that junior doctors who actually take on teaching roles are not eligible for professional development of teaching offered by MEU. This devalues the teaching contribution made by junior colleagues and sends a negative signal about teaching. R14 and other participants at RH expressed concern about assigning teaching duties to those junior doctors who haven’t received any training as a teacher.\u003c/p\u003e\u003ch2\u003eMissed Opportunity to Recognise Clinical Teaching?\u003c/h2\u003e\u003cp\u003eA mismatch exists in how clinical teaching is recognised in promotion criteria for doctors. Since Oman Medical Speciality Board (OMSB) was established in 2006 aiming to “achieve excellence in postgraduate medical education, training, assessment and accreditation” in order to “educate the next generation of leaders in medicine” (Oman Medical Speciality Board, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2010\u003c/span\u003e, p. 3). An important medical bylaw passed in 2014 highlighting the value of teaching in a clinical setting by specifying teaching is a criterion for promotion to senior consultant: doctors “should be involved in teaching and educational activities at educational, training and health institutions” (Ministry of Justice and Legal Affairs, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2014\u003c/span\u003e, pp. 87–88).\u003c/p\u003e\u003cp\u003eHowever, the bylaw does not mention teaching as a criterion for promotion below the rank of senior consultant or once a doctor becomes a senior consultant. As a result, some doctors opt-out from their teaching duties once they are promoted to senior positions. This unfortunate omission is perceived as a ‘missed opportunity’ on the part of the Ministry of Health to promote clinical teaching for all doctors. Both R11 and R12 at RH believe that some doctors opt out of teaching because there are no consequences for not teaching, especially when teaching is perceived as an extra burden. R11 said “I have not been given a dedicated time [for teaching], so it’s understood that I will teach if I have time. If I don’t have time, I’ll not teach. So there is no compulsion on me to teach.” (R11, RH)\u003c/p\u003e\u003ch3\u003eResearch Limitations\u003c/h3\u003e\u003cp\u003eOne constraint of this study is about the limited access to senior doctors due to their busy and charged workload. Although the support from the directors of both hospitals was obtained, not all senior doctors were available. Those doctors who were busy or unavailable at the time was unfortunately not interviewed in this study.\u003c/p\u003e\u003cp\u003eWhile there were only 5 female participants out of the overall group of 27 senior doctors, this does not under represent the female voice in this study as only 6% of senior doctors in Oman are female (Mohamed et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusions and Recommendations","content":"\u003cp\u003eThere is limited research on clinical teaching at hospitals in Oman. This qualitative study has provided rich and valuable insights into how senior doctors perceive their teaching roles in clinical settings at SQUH and RH. Twenty-seven senior doctors at the two hospitals were interviewed. Critical realism which considers the empirical, the actual and the real domains of a situation was used as the methodology. It emerged that while participants appreciated the relational aspect of their teaching roles, RH doctors felt their contributions were undervalued. Unlike their counterparts at SQUH, RH doctors were less likely to consider teaching as an integral part of their professional duties. There was a lack of protected time for teaching for RH doctors and the teaching bonus for them was simply not comparable to the teaching rewards for SQUH doctors. There is also a perceived lack of clarity surrounding the teaching roles in the actual domain despite the existence of some guidelines for medical teachers from the Oman Medical Specialty Board (OMSB).\u003c/p\u003e\u003cp\u003eAlthough medical authorities recognize teaching as one of the dual missions of Omani hospitals, RH participants continued to seek formal recognition for their teaching roles. This lack of acknowledgement likely stemmed from RH's failure to adequately support its medical teachers, which has fostered a sense of exclusion and a diminished sense of belonging. The issue is further exacerbated by the restrictive criteria set by the Medical Education Unit (MEU, currently known as Medical Education and Informatics Department) at Sultan Qaboos University for professional development, which primarily benefits senior doctors while excludes many junior doctors. Moreover, Oman's 2014 medical regulation, which includes teaching as a criterion for promotion to senior positions, does not extend this requirement to ranks below or beyond senior posts. This omission has led some senior doctors to opt out of teaching altogether, while others regard it as an additional burden on top of their clinical responsibilities.\u003c/p\u003e\u003cp\u003eFuture research could expand on these findings by incorporating the perspectives of other stakeholders, including junior doctors, healthcare professionals, and medical students. Clinical teaching can be explored from other levels i.e. undergraduate, postgraduate or residency. Additionally, how to balance teaching duties with other professional responsibilities remains a central topic for many doctors. Gender disparities in Omani medical field, as in many other countries, makes it essential to explore the unique experiences of female doctors.\u003c/p\u003e\u003cp\u003eDrawing on the findings of this study, we would like to make some recommendations for the Omani government. First, a national standard to clarify teaching roles, which is equivalent to the UK professional standards framework and standards from the Academy of Medical teachers, is needed (Academy of Medical Educators, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Frank et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; The Higher Education Academy, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Second, a national policy for allocating teaching funds and rewards, protecting teaching time, and offering access to teaching materials including libraries for all medical teachers is required. Next, it is imperative to include junior doctors in professional development for teaching, who carry out most of the clinical teaching. We also think that it is important for the Ministry of Health and its hospitals to work together to create a culture which promotes and cultivates medical teachers’ teaching identity. This will shift the perception from “some doctors who teach” to “being a doctor is being a teacher”. Medical schools certainly should take a more active role in forming doctor’s teaching identity in the early years of medical students, for example by including clinical teaching as part of the curriculum.\u003c/p\u003e\u003cp\u003eCreating a culture of valuing medical teachers, developing a strong teaching identity, and forming a sense of belonging as being a medical teacher in a hospital are not easy. All stakeholders need to work together to offer the best quality of medical education for our future doctors in Oman.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eMEU\u003c/strong\u003e Medical Education Unit (currently known as Medical Education and Informatics Department)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRH\u003c/strong\u003e Royal Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSQUH\u003c/strong\u003e Sultan Qaboos University Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGCC\u003c/strong\u003e Gulf Cooperation Council\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCHPE\u003c/strong\u003e Certificate Course in Health Professions Education\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOMSB\u003c/strong\u003e Oman Medical Speciality Board\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSQU-CoMHS\u003c/strong\u003e Sultan Qaboos University College of Medicine and Health Sciences\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRCPSG\u003c/strong\u003e Royal College of Physicians and Surgeons of Glasgow\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003cbr\u003e\u003c/strong\u003eThis study was conducted in accordance with the ethical standards set out in the Declaration of Helsinki. Ethical approval was obtained from multiple bodies. The study was first reviewed and approved by the Moray House School of Education and Sport Ethics Committee at the University of Edinburgh, UK, and was deemed to fall under Level 1 of the ethics screening process (i.e., low risk, not requiring formal committee review).\u003c/p\u003e\n\u003cp\u003eSubsequently, ethical approval was secured from the Research and Ethical Review Committee at the Ministry of Health, Oman (Reference No. MoH/DGPS/CSR/PROPOSAL_APPROVED/38/10230), and from the Medical Research and Ethics Committee at Sultan Qaboos University (Reference No. SQU_EC 077/16).\u003c/p\u003e\n\u003cp\u003eAll participants were provided with a detailed participant information sheet, outlining the study purpose, voluntary nature of participation, and the measures taken to ensure confidentiality and data security. Written informed consent was obtained from all participants prior to data collection. Participants were informed that they could withdraw at any time and that their identities would remain anonymous through the use of pseudonyms.\u003c/p\u003e\n\u003cp\u003eDigital recordings, consent forms, and transcripts were securely stored in password-protected files and in locked cabinets, and data handling was conducted in compliance with the UK Data Protection Act (2018) and the University of Edinburgh’s Data Protection Policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u003c/strong\u003eAll participants gave informed consent for their anonymized quotations and contributions to be published in academic outputs resulting from this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e\u003c/strong\u003eThe datasets generated and analysed during the current study are not publicly available due to confidentiality agreements with participants. However, de-identified excerpts are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003cbr\u003e\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eThis research was conducted as part of a doctoral thesis, which was funded by\u0026nbsp;Ministry of Higher Education, Research and Innovation,\u0026nbsp;Oman\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003cbr\u003e\u003c/strong\u003eLaila Moosa Al Zidjali is the principal author of this article, which is based on her doctoral research completed in 2022. She was responsible for the conception of the study, study design, data collection, data analysis, and manuscript preparation. Kuang-Hsu Chiang contributed to the conception, analysis, and interpretation of data and provided substantive revisions to the manuscript. Hamish Macleod contributed to the interpretation of data and provided feedback on the final draft. All authors approved the submitted version and agree to be personally accountable for their own contributions and for the integrity and accuracy of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article is derived from Laila Al Zidjali’s doctoral research at the University of Edinburgh, which was awarded in 2022. The authors extends their gratitude to the participants for generously sharing their experiences. The author 1 would like to express her sincere thanks to her PhD supervisors, Dr Kaung-Hsu Huang and Dr Hamish Macleod, for their guidance throughout the study. The support of the study participants, and the institutional and ethical approval provided by the Sultan Qaboos University, the Royal Hospital, and the Ministry of Health in Oman, is also gratefully acknowledged.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAcademy of Medical Educators. Professional Standards for medical, dental, and veterinary educators. Third Edn). Academy of Medical Educators; 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArcher MS. Realist Social Theory: The Morphogenetic Approach. Cambridge University Press; 1995.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArcher MS. Social theory and the analysis of society. In: May T, Williams M, editors. Knowing the social world. Open University; 1998. pp. 69\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArcher MS, Decoteau C, Gorski P, Little D, Porpora D, Rutzou T, Smith C, Steinmetz G, Vandenberghe F. 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Educ + Train. 2000;42(2):83\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWagner R, Weiss KB, Passiment ML, Nasca TJ. Pursuing Excellence in Clinical Learning Environments. J Graduate Med Educ. 2016;8(1):124\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhite JP, Armstrong H, Armstrong P, Bourgeault I, Choiniere J, Mykhalovskiy E. The impact of managed care on nurses\u0026rsquo; workplace learning and teaching. Nurs Inq. 2000;7(2):74\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Board certification indicated the education level achieved by physicians beyond their undergraduate certification as medical doctors and as a minimal standard of required core competencies in their chosen specialty.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"medical doctors’ professional development, medical policies, clinical training teaching, senior and junior medical doctors, critical realism in medical contexts, Oman medical education, hospital working environment, teacher identity teaching experience, medical doctor mentoring experience","lastPublishedDoi":"10.21203/rs.3.rs-6517354/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6517354/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis qualitative study aims to explore senior doctors\u0026rsquo; experiences and perceptions of their teaching roles in clinical settings at two hospitals, the Sultan Qaboos University Hospital (SQUH) and Royal Hospital of the Ministry of Health (RH), in the Sultanate of Oman.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn order to obtain an understanding of doctors\u0026rsquo; clinical teaching experiences, this qualitative study uses critical realism as its methodology. In-depth semi-structured interviews were conducted with twenty-seven senior doctors at SQUH and RH. The three-layered realities of critical realism - the empirical, the actual and the real, help generate rich findings and insightful analyses.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe study shows that in the empirical domain, senior doctors perceived their educational roles in a wide spectrum from job titles to the relational nature of their teaching. It was also found that RH doctors felt their teaching roles are less valued than SQUH doctors due to their perception that the teaching mission of their hospital is not formally recognised. Interestingly in the actual domain, there is a lack of clear definition for medical teachers in policies. To explore this further, it is found that in the real domain, although dual missions of Omani hospitals, teaching and health care, are confirmed by Omani authorities, there is seen to be a neglect of educational roles at RH. It also discovered that professional development offered by the Medical Education Unit (currently known as Medical Education and Informatics Department) for medical teachers is limited due to its exclusion of junior doctors, who do a good amount of clinical teaching. Further, it was perceived as a missed opportunity for the Ministry of Health to recognise medical teachers by not including teaching experience in the promotion criteria for all ranks of seniority.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis qualitative study offers an in-depth understanding of senior doctors\u0026rsquo; experiences of clinical teaching at two hospitals in Oman. The lack of clear policies and formal recognition for doctors\u0026rsquo; teaching roles, no protected time for teaching, and differential teaching rewards have made RH doctors feel their roles as medical teachers unvalued compared to SQUH doctors. For the Omani government, hospital doctors in Oman would benefit from a positive culture which values medical teaching, gives a sense of belonging for medical teachers in hospitals, offers clear definitions for their teaching roles in policies, and extends the professional development to junior doctors. The study is of value for future research investigating the balance of teaching with other duties of a doctor, and from different perspectives; for example, junior doctors, medical students and other health professionals.\u003c/p\u003e","manuscriptTitle":"Doctors Being Medical Teachers? Senior Doctors’ Experience of Teaching Roles at Two Hospitals in Oman","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 03:25:02","doi":"10.21203/rs.3.rs-6517354/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-01T06:52:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-30T11:36:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-24T09:17:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"227029166676275854297577076786895143158","date":"2025-06-19T23:01:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69317941226820898301584471348043934738","date":"2025-06-18T13:59:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45573481618924021603842337724877574687","date":"2025-06-12T13:57:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-10T13:14:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-09T10:36:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-05T16:55:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-06-05T16:51:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"945ade32-72ab-4db1-b085-c1a1b0eb7597","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:06:21+00:00","versionOfRecord":{"articleIdentity":"rs-6517354","link":"https://doi.org/10.1186/s12909-025-07904-2","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-10-17 15:57:37","publishedOnDateReadable":"October 17th, 2025"},"versionCreatedAt":"2025-06-12 03:25:02","video":"","vorDoi":"10.1186/s12909-025-07904-2","vorDoiUrl":"https://doi.org/10.1186/s12909-025-07904-2","workflowStages":[]},"version":"v1","identity":"rs-6517354","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6517354","identity":"rs-6517354","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}