Showing papers in "Medical Education in 1989"

Essentials of problem-based learning.

Abstract: A symposium was held under the auspices of the World Federation for Medical Education, sponsored by the King’s Fund, and designed for the interchange of views between experts in medical education who had special experience of problem-based learning (PBL). The Report of the Symposium aims to inform teachers in undergraduate, postgraduate and continuing medical education, and others, e.g. administrators, who seek to learn more about PBL. It is also for the use of the various organizations in the field of medical education, e.g. the World Federation for Medical Education, and the World Health Organization, which has made a considerable investment in PBL. WHO reports stress that PBL, provided that it is based on relevant priority health problems of unchallengeable relevance, is a very valuable educational approach. While the main thrust of WHO in the medical educational field has its greatest emphasis on community-oriented education and active learning, it is however clear that there is no significant dichotomy between community-oriented education and problembased learning. Both community health problems and individual patient problems should be used. The report is not a manual of guidance for those considering instituting PBL, for there are already valuable publications of this type (see bibliography). As its title implies, it reviews the essential ingredients of PBL, a most important method of learning and teaching. Correspondence: Professor H. J. Walton, President, World Federation for Medical Education, International Medical Education, University Medical School, Teviot Place, Edinburgh EH8 9AG, UK.

The medical school as a social organization: the sources of resistance to change

Abstract: Medical schools vary by nation and by culture but, for students, the experience appears to be very similar. Also, despite a half-century of radical changes in medical practice, education as a process of socialization for the profession is relatively unchanged. At the same time, medical educators have frequently instituted curricular reforms. To analyse this history of reform without change, this paper first establishes what the content and structure of medical education is, and how it came to be that way; second it traces a process whereby the scientific mission of academic medicine has crowded out its social responsibility to train for society's most basic health-care delivery needs. The main argument is that medical education's manifest humanistic mission is little more than a screen for the research mission that is the major thrust of the institution's social structure.

A retrospective study of attitude change during medical education

Abstract: A retrospective attitude questionnaire was administered to 70 of 157 graduating seniors at the end of the medical school year. Students perceived that they became more cynical during medical education. In addition, they perceived that they were more concerned with making money, more concerned for patients, and more helpful. These findings relate to the developmental stressors of medical education as they affect the individual student. Burn-out and impairment are possible consequences; a preventive approach is advocated.

Education for practice: the role of practical experience in undergraduate and general clinical training

Abstract: A questionnaire and interview study in two London medical schools reviewed the undergraduate curricula and house year from the perspectives of graduates one year after qualification. Data from 113 house officers (44%), obtained by questionnaire and interview, showed general satisfaction with training. However, they also saw undergraduate preparation as deficient in exposure to some practical procedures and common conditions, and several difficult communication skills were not taught. Graduates reported that they would have liked more experience as undergraduates in resuscitation, lumbar puncture, inserting nasogastric tubes, endotracheal intubation, and in managing diabetic keto-acidosis, asthmatic attacks, myocardial infarcts and respiratory failure. The purposes of the house year and the articulation between it and the undergraduate years require clarification.

Anxiety and study methods in preclinical students: causal relation to examination performance

Abstract: Stress and anxiety are substantially raised in many preclinical students in their first year at medical school. Although correlated with poor end-of-year examination performance, anxiety levels did not cause poor performance, but were themselves caused by previous poor performance in sessional examinations. Study habits showed declining deep and strategic approaches, and increasing surface ('rote-learning') approaches. Surface learning correlated with poor end-of-year examination performance, and was a result of previous poor sessional examination performance. Deep learning did not correlate with performance, whereas strategic learning correlated positively with examination success, even when measured 2 years previously during application to medical school.

The effectiveness of immediate feedback during the objective structured clinical examination.

Abstract: Using eight different physical examination or technical stations, 400 examinations were conducted to evaluate the effectiveness of immediate feedback during the Objective Structured Clinical Examination (OSCE). The test group comprised 50 medical students who underwent a standard 4-minute examination followed by 2 minutes of feedback. Immediately following feedback the students repeated an identical 4-minute examination scored by the same examiners. The control group consisted of 50 students from the same class who underwent an identical testing sequence, but instead of receiving feedback, they were instructed to continue their examinations for an additional 2 minutes before repeating the stations. Simple repetition of the task did not significantly improve score (mean increase 2.0%, NS). Extending the testing period from 4 to 6 minutes resulted in a small but significant increase in score (mean 6.7%, P less than 0.001). However, there was a much larger increase in the scores obtained following 2 minutes of immediate feedback compared to pre-feedback performance (mean 26.3%, P less than 0.0001). The majority of students and examiners felt that feedback, as administered in this study, was valuable both as a learning and teaching experience. Short periods of immediate feedback during an OSCE are practical and can improve competency in the performance of criterion-based tasks, at least over the short term. In addition, such feedback provides students with valuable self-assessment that may stimulate further learning.

The curriculum of communication skills teaching at Maastricht Medical School

Abstract: Summary. In the Skillslab at Maastricht Medical School students are prepared for their first encounters with patients. Students can focus on individual skills, separately mastering each skill in a controlled systematic manner. With this foundation students are better equipped to face the complex intellectual and emotional demands of real patients. A large proportion of training concerns communication skills. Features of Skillslab communication skills training programme are: 1 its continuity (once every 2 weeks, from year 1 to year 6); 2 a gradual increase of complexity in skills (basic interview skills, phases of interviews, entire interviews, problem patients); 3 a gradual increase of complexity in practice situations (apparatus, role-playing, simulated patients, real patients). Evaluation shows students' and teachers' satisfaction with the programme. Comparison with conditions required for interpersonal skills training shows that these are fully met. However, there are drawbacks, which are described.

Increasing empathy among medical students

Abstract: The objective of the research was to evaluate the short- and long-term effectiveness of teaching medical students interviewing skills. Methods of teaching communication skills included a workshop for clinical instructors, as an indirect approach, a workshop for medical students, as a direct approach, and a combination of both. Results demonstrated that in order to stimulate medical students to use supporting-interview skills, they themselves should participate in an interpersonal skills workshop. Being taught these skills by teachers who have participated in the workshop does not have the same positive effect.

Training and experience of examiners.

Abstract: Variation in the accuracy of examiner judgements is a source of measurement error in performance-based tests. In previous studies using doctor subjects, examiner training yielded marginal or no improvement in the accuracy of examiner judgments. This study reports an experiment on accuracy of scoring in which provision of training and background of examiners are systematically varied. Experienced teaching staff, medical students and lay subjects were randomly assigned to either training or no-training groups. Using detailed behavioural check-lists, they subsequently scored videotaped performance on two clinical cases, and accuracy of their judgments was appraised. Results indicated that the need for and effectiveness of training varied across groups: it was least needed and least effective for the teaching staff group, more needed and effective for medical students, and most needed and effective for the lay group. The accuracy of the lay group after training approached the accuracy of untrained teaching staff. Trained medical students were as accurate as trained teaching staff. For teaching staff and medical students training also influenced the nature of errors made by reducing the number of errors of commission. It was concluded that training varies in effectiveness as a function of medical experience and that trained lay persons can be utilized as examiners in performance-based tests.

A written test as an alternative to performance testing

Abstract: Performance tests are logistically complex and time consuming. To reach adequate reliability long tests are imperative. Additionally, they are very difficult to adapt to the individual learning paths of students, which is necessary in problem-based learning. This study investigates a written alternative to performance-based tests. A Knowledge Test of Skills (KTS) was developed and administered to 380 subjects of various educational levels, including both first-year students and recently graduated doctors. By comparing KTS scores with scores on performance tests strong convergent validity was demonstrated. The KTS failed discriminant validity when compared with a general medical knowledge test. Also the identification of sub-tests discriminating between behavioural and cognitive aspects was not successful. This was due to the interdependence of the constructs measured. The KTS was able to demonstrate differences in ability level and showed subtle changes in response patterns over items, indicating construct validity. It was concluded that the KTS is a valid instrument for predicting performance scores and could very well be applied as supplementary information to performance testing. The relative ease of construction and efficiency makes the KTS a suitable substitute instrument for research purposes. The study also showed that in higher ability levels the concepts which were meant to be measured were highly related, giving evidence to the general factor theory of competence. However, it appeared that this general factor was originally non-existent in first-year students and that these competencies integrate as the educational process develops.

Lectures and skills workshops as teaching formats in a history-taking skills course for medical students.

Abstract: The consulting skills acquired by medical students during their training are an important determinant of their ability to conduct adequate and efficient clinical interviews. These skills comprise: the acquisition of medical knowledge and the ability to apply this; and communication skills required to obtain full, accurate clinical histories from patients and to be able to give to patients the information they need to comply with prescribed regimens. Until recently, consulting skills training has certainly not had a high profile in medical curricula, despite evidence that students do not gain sufficient expertise during their medical training. A history-taking skills course within the Austin Hospital Clinical School, utilizing mass lecture and small-group skills workshops is described. Independent evaluation of students' videotaped interviews with patients, completed before training, after mass lectures and following small-group workshops, showed that students trained in consulting skills demonstrated significant improvements in interview skills and techniques, compared with a similar group of students for whom training followed the more traditional model. Whilst there were some improvements after mass lectures, most significant gains in history-taking skills were obtained following skills workshops. Ongoing evaluation of these students will determine if these short-term improvements in consultation skills persist over their clinical training and internship.

Changing medical education.

Abstract: This paper is based on one which was prepared to support the World Conference of the World Federation for Medical Education in August 1988. It is designed to provide a broad perspective on the essential elements of an educational change process. The paper covers the stages in designing a change strategy and highlights the difficulties that any change agent is likely to encounter. A review of the history of change in education and organizations is followed by discussion of the need for change and the ability to change. Reasons for resistance to change are presented and discussed. Implementation and reinforcement of change are considered before a final section on evaluation.

An evaluation of the effectiveness of a computer simulation of anaesthetic uptake and distribution as a teaching tool.

Abstract: Summary. Gas Man® is an interactive, microcomputer-based simulation and tutorial designed to teach the principles of anaesthetic uptake and distribution. Using two resident groups, one at a primary university-teaching hospital and the other at a medical school affiliated community hospital, the authors compared residents' knowledge of the subject prior to exposure to the tutorial and the average time spent using the program during a self-paced instruction period. Both groups not only significantly improved their knowledge of uptake and distribution 8 weeks after using this program, but wished to spend additional time with it, implying that it was a pleasant and satisfying way to learn. Computer simulation has the potential to be an important teaching tool in an anaesthesia residency training programme.

Communication skills training for medical students: an integrated approach

Abstract: Skills of communication are not easily taught to medical students. Three main clinical departments (general practice, medicine and mental health) of the Medical Faculty of the Queen's University, Belfast, introduced an integrated course in January 1988 to teach the basic principles. The course is held at the beginning of clinical training and is an integral part of the introductory clinical course. It was introduced in response to the Report of a Working Party of the Education Committee of the General Medical Council (1987) which advocated the need for improved training in history-taking and communication. It is a 12-week course and every Monday and Friday afternoon from 1400 to 1700 hours 12 students are seconded from ward work, four to the Department of Medicine, four to the Department of General Practice and four to the Department of Mental Health. Hand-outs about information to be obtained and interview style are standardized and the principles to be followed are clearly defined in an aide-memoire. Staff from the Departments of General Practice and Mental Health experienced in teaching communication by videotape feedback and analysis of consultations prepared 12 tutors for their role and responsibilities. Procedures to be followed were carefully explained to all students beforehand. General practice and psychiatry traditionally have established teaching programmes in communication but the inclusion of the Department of Medicine has made a significant impact. Students have come to realize that the taking of a good history demands as much skill as the physical examination of the patient and is an important aspect of any clinical assessment.

Some phenomena of medical students' diagnostic problem-solving.

Abstract: Summary. This paper introduces a perspective on medical problem-solving that derives from recent studies of content-related learning. Results from a study of fourth-year medical students' approaches to understanding a data base of significant facts about a patient (a problem synthesis) are presented. By analysing data collected in interviews, we obtain categories of description that portray the qualitatively different ways in which the information in diagnostic problems is handled by these students. Two major categories describe the variability in approach: ‘ordering’ and ‘structuring’. The latter category contains elements that most clinical teachers would regard as desirable; the former represents a less satisfactory approach. We provisionally identify two diagnostic strategies within each of these categories. The perspective has implications for improving instruction and assessment.

Types of problem students encountered by clinical teachers on clerkships.

Abstract: Summary The teachers who play the all-important role of enabling students to learn on clinical clerkships must balance the two essential skills of being a good role model and maintaining objectivity in order to identify students with a variety of problems This study describes the findings of a survey that identifies both the type of the problems that most bother teachers and the relative frequency of those problems Non-cognitive problems (poor interpersonal skills and non-assertive, shy students) were identified by teachers as being seen at the same relative frequency but posing greater difficulty than cognitive problems (poor integration skills, disorganization, poor fund of knowledge, etc) A variety of the types of interventions to these problems are discussed

Approaches to learning in a problem-based medical programme: a developmental study.

Abstract: In this study we investigate how the introductory phase of the problem-based medical programme in Maastricht affects the study methods of students. On the first day of the academic year, 142 men and women medical students completed the Short Inventory of Study Approaches and again at the end of the introductory period. The study indicates that these study methods are fostered by training in problem-based learning given during the introductory period.

Analysing qualitative data: ethnography and the evaluation of medical education.

Abstract: Quantitative methods of evaluating the outcomes of medical education may not always deliver the information which course organizers and teachers most need in order to improve their courses. Qualitative methods of research could provide such information. However, the use of qualitative methods has been limited by the difficulties associated with the analysis of subjective data and by the validity of its results. Qualitative data from an evaluation of the 2-year part-time MSc Course in General Practice at Guy's and St Thomas's Hospitals are presented and a rigorous method of analysis demonstrated. It is argued that for qualitative research validity is progressively achieved through the process of analysis, unlike experimental research where validity is ascribed in the research design. The relationship of research methods and approaches to evaluation is discussed and the potential contribution of qualitative research methods is outlined.

Breaking bad news: medical undergraduate communication skills teaching and learning.

Abstract: Teaching on the theme of 'breaking bad news' was selected for special development as part of an introductory course on communication skills for preclinical medial students in 1987. Eight parents of handicapped children and three patients terminally ill with neoplastic diseases cooperated in a series of semi-structured group discussions in which students were encouraged to interact with patients and children. The patients/parents readily assumed the role of teachers and where it was possible, they participated in similar sessions the following year. Analysis of questionnaires indicated that the plan had proved acceptable to patients, relatives and students. Follow-up of student opinion one year later indicated that students felt they had derived benefit from these opportunities to learn first-hand from patients and parents of handicapped children.

Medical students' attitudes to old people and career preference: the case of Nottingham Medical School.

Abstract: Summary. Medical students' attitudes to the elderly population were compared at entry to and exit from a month-long clinical attachment in the Department of Health Care of the Elderly at Nottingham University. The study investigated clinical students for the 1983–4 and 1986–7 academic years using a questionnaire employing a Rosencranz-McNevin semantic differential scale to measure general attitudes to old age and a Likert scale to measure attitudes to medical care. A question was also asked about career preferences. Improvements in attitudes during the month were noted for both cohort groups, but different trends for the two groups are discussed in the context of the growing preclinical effects of such a specialist department in a medical school.

Effects of the vocational training of general practice consultation skills and medical performance.

Abstract: Summary. The effects of the vocational training of general practitioners in the Netherlands on the consultation skills and medical performance of junior doctors were studied. Results obtained at a training institute providing systematic training in these skills (Nijmegen) were compared with those at an institute taking a problem-based learning approach (Groningen). Trainees (n =63) audiotaped consultations and recorded their medical performance at the start and at completion of training. The skills were evaluated with the aid of validated criteria and medical ‘protocols’. Data on 631 pre-training and 624 post-training consultations were compared. Changes in consultation skills and medical performance occurred at both institutes and proved more marked at the institute providing systematic training. Improved medical performance was found to be associated with improved consultation skills. Enhanced clinical knowledge was found to be related to improved medical performance and consultation skills. The most profound changes were found in junior doctors who had started at a lower level of consultation skills and medical performance.

Gender as a factor in student learning: preliminary findings

Abstract: Major differences exist between the abilities, attitudes and personalities of men and women medical students (Walton 1968; Clack e ta l . 1976; McGrath & Zimet 1977; Ferrier & Woodward 1982; Bergquist et al. 1985; Huxham et al. 1985; Alexander & Eagles 1986; El-Hazmi et al. 1987; Marshall 1987). Though the need has been stressed to give attention in medical education research to the possibility of gender differences (Alexander & Eagles 1986), this variable was evaluated in only one of several recent studies (Newble & Gordon 1985; Coles 1985; Chessel 1986; Mirtenson 1986) describing the application to medical students of the Lancaster Approaches to Studying Inventory (LI) (Entwistle & Ramsden 1983). Moreover, comparative statistical data were not recorded in that single report (Chessel 1986). We have administered the LI to medical students at the University of Pretoria and certain notable intraclass gender differences were found. The LI is a self-report questionnaire comprising 64 items. We used the version described by Ramsden (1983). The items are grouped into 16 subscales, of which 14 arc themselves combined to form four scales. Meanings of the scales and subscales are briefly outlined in Table 1. To

The medical school as a social organization

Abstract: Summary. The paper reviews sociological research on the medical school as a social organization from the 1950s to the present. Despite significant differences between societies in the organization of medical education, such research has been largely confined to the USA. Some reasons for this are suggested. Ways in which the climate and organization of medical schools—at least in Great Britain — have changed in the recent past are described as well as reasons for such changes. It is argued that more research into these processes and into the organizational obstacles to change, including cross-national studies, are needed.

What 'makes' a good doctor?

Abstract: Summary. The relation between gender, personality, school scores, grades at medical school and eventual achievement as a medical practitioner 8 years after qualifying has been explored by path analysis in a cohort of medical students. Factor analysis of data derived from a questionnaire identified a significant factor accounting for 75% of the common variance of the professional achievement scores. Standardized path coefficients were computed to indicate the relative importance of the causal factors to postgraduate achievement. Gender played an important role at many levels. For example it was apparent that many of our women graduates were seriously disadvantaged in their professional careers. Of the school subjects, chemistry was a surprising long‐term predictor of postgraduate achievement. Academic achievement during medical school training, particularly in the final year, was a significant predictor, while personality attributes made their contribution to one or other aspect of achievement at earlier stages in training but made little additional direct contribution to postgraduate performance. 1989 Blackwell Publishing

The use of videorecordings of medical postgraduates in improving clinical skills

Abstract: The examination for membership of the Royal Colleges of Physicians has a high failure rate despite intensive clinical coaching provided by many postgraduate courses. One of the main difficulties appears to be the failure of candidates to identify specific shortcomings in their clinical behaviour. In this study videorecording was used as a method of self-appraisal enabling the candidate to identify strengths and weaknesses. The evidence from the study suggests that self-appraisal by videorecording should be used as an adjunct to clinical instruction.

Psychological tests to measure the effects of medical education on students' interpersonal skills.

Abstract: Summary. The consulting skills required of medical students and practitioners have been categorized into a number of specific skills, two of which are: students’ ability to empathize with the patient; and ability to decode non-verbal cues given by the patient in the interview. Training programmes to improve students’ consulting skills are usually evaluated using analysis of students’ actual interview behaviours with patients. Broad psychological and personality tests have also been used to measure changes in students’ interviewing skills, but have generally not been successful. The hypothesis is advanced that more specific tests of the skills of interviewing, such as non-verbal sensitivity and empathy, would detect changes in students’ ability to display these skills. As part evaluation of a consulting skills training programme, clinical students completed psychological tests of empathy and non-verbal sensitivity. Subsequent comparisons between trained and control student groups revealed no clear pattern in test results. These data suggest that specific psychological tests of empathy and non-verbal sensitivity may be no more effective in detecting changes in students’ interpersonal skills than global personality measures.

A curriculum on medical ignorance.

Abstract: The information and technology explosions in medicine have exposed the vast realm of ignorance in human biology as well as the transiency of accepted knowledge and shortcomings of instructional methods which foster rote memorization, excessive reliance on conflicting data bases, and short-answer testing. To circumvent this serious deficiency in medical education, we have initiated a multifaceted Curriculum on Medical Ignorance consisting of 'questioning' seminars and hands-on clinical and laboratory experiences. This teaching programme not only emphasizes medicine's current deficiencies and limited insight into disease processes (i.e. ignorance) but also assists students in developing attitudes and behaviours to investigate basic biologic and clinical unknowns while rendering sound everyday clinical decisions in the face of fragmentary understanding. Based on evaluative feedback over the past 3 years, participants have made substantial progress towards recognizing and dealing constructively with medical ignorance and the limitations of 'knowledge of the day', thereby preparing them for the certain uncertainty of future medical practice.

The curriculum for the year 2000

Abstract: Emerging public health problems, alterations in the nature of the medical profession and changes in individual student and practitioner needs are identified. The implications of these developments for modification of the content, organization, setting and instructional strategy of the medical education programme are discussed. A model for systematic consideration of societal, professional and individual needs in curricular reform is proposed and a strategy for change is suggested.

Setting educational priorities for learning the concepts of population health

Abstract: Summary. Following the World Health Organization's policy of ‘Health for All by the Year 2000′, doctors are increasingly being seen as health care providers to populations of patients, in addition to their more traditional role as doctors to individuals in a one-to-one encounter. In order for doctors to take on this expanded role, they must learn the knowledge and skills appropriate to population health. In this paper, we propose a method of educational priority-setting which allows educational planners to identify those diseases and adverse health conditions most appropriate for studying the concepts of population health. Using the Measurement Iterative Loop of Tugwell and colleagues as a framework, a table of Priority Illness Conditions was developed and compared with a previous priority list developed from a survey of clinical teachers at the McMaster University Medical School. Discussion of the implications for this approach in setting educational priorities at undergraduate, postgraduate and continuing medical education levels is presented, along with a review of possible shortcomings and caveats in using this approach.

A new approach to preparing students for academic medicine.

Abstract: Critical thinking and self-directed learning by students are goals strongly endorsed by medical educators. Teaching medical interviewing and physical diagnosis skills is one of the most important tasks in medical school. An elective for fourth-year students was designed to address both areas. Ten senior medical students spent one month with a teaching staff member and fellow in general medicine. Part of the course was designed for independent problem-solving posed by sophisticated medical problems encountered in a general medicine practice. Skills in problem formulation, reading and assessing the medical literature, and communicating with peers were learned or improved. In the remainder of this course five pairs of senior students precepted 28 randomly chosen second-year students and taught medical interviewing and physical diagnosis. Techniques of teaching and basic pathophysiology were reviewed, and role-playing, feedback, demonstration and role-modelling were used.