Showing papers in "Medical Education in 2001"

Interdisciplinary education and teamwork: a long and winding road.

Abstract: Purpose This article examines literature on interdisciplinary education and teamwork in health care, to discover the major issues and best practices. Methods A literature review of mainly North American articles using search terms such as interdisciplinary, interprofessional, multidisciplinary with medical education. Main findings Two issues are emerging in health care as clinicians face the complexities of current patient care: the need for specialized health professionals, and the need for these professionals to collaborate. Interdisciplinary health care teams with members from many professions answer the call by working together, collaborating and communicating closely to optimize patient care. Education on how to function within a team is essential if the endeavour is to succeed. Two main categories of issues emerged: those related to the medical education system and those related to the content of the education. Conclusions Much of the literature pertained to programme evaluations of academic activities, and did not compare interdisciplinary education with traditional methods. Many questions about when to educate, who to educate and how to educate remain unanswered and open to future research.

Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey

Abstract: Objective To assess psychological changes in medical students in Antalya, Turkey during their undergraduate education. The first-year follow-up outcomes are presented in this article. Design All first-year undergraduate students were given a detailed, self-report questionnaire and another in the second year. They were asked to complete the General Health Questionnaire (GHQ), the Spielberger State–Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI). Setting The Faculties of Medicine, Economics and Physical Education (PE) of the Akdeniz University, Antalya, Turkey. Participants All first-year undergraduate students in the Faculties of Medicine, Economics and PE who were registered in 1996. Results The findings showed that psychological test scores on the GHQ, the STAI and the BDI rose significantly in medical students between the first and second years. Using the GHQ, with different cut-off scores, the percentage of students scoring above the thresholds was higher in medical students in year 2, compared with economics and PE students. In addition, the scores for some stressful life events of medical students showed a significant rise from year 1 to year 2. Multiple regression analyses indicated that some stressful life events related to social activities were associated with the psychological test scores for medical students. Conclusion The results indicate that there is a decrease in the psychological health of first-year medical students. Some inadequacies in the social activities of the students might play a role in this type of disturbance.

Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning.

Abstract: Objectives The belief that the effectiveness of patient care will improve through collaboration and teamwork within and between health care teams is providing a focus internationally for ‘shared learning’ in health professional education. While it may be hard to overcome structural and organizational obstacles to implementing interprofessional learning, negative student attitudes may be most difficult to change. This study has sought to quantify the attitudes of first-year medical, nursing and pharmacy students’ towards interprofessional learning, at course commencement. Design The Readiness for Interprofessional Learning Scale (RIPLS) (University of Liverpool, Department of Health Care Education), was administered to first-year medical, nursing and pharmacy students at the University of Auckland. Differences between the three groups were analysed. Setting The Faculty of Medical and Health Sciences, University of Auckland. Results The majority of students reported positive attitudes towards shared learning. The benefits of shared learning, including the acquisition of teamworking skills, were seen to be beneficial to patient care and likely to enhance professional working relationships. However professional groups differed: nursing and pharmacy students indicated more strongly that an outcome of learning together would be more effective teamworking. Medical students were the least sure of their professional role, and considered that they required the acquisition of more knowledge and skills than nursing or pharmacy students. Conclusion Developing effective teamworking skills is an appropriate focus for first-year health professional students. The timing of learning about the roles of different professionals is yet to be resolved.

Adaptive and maladaptive perfectionism in medical students: a longitudinal investigation.

Abstract: Objectives The personality of medical students may have an important impact on both their academic performance and emotional adjustment during medical school. There has been little systematic study of the impact of perfectionism on medical students. The present study sought to compare the perfectionism profile of medical students with that of a general arts student group and to examine the relationship among perfectionism, distress symptoms and academic expectations and satisfaction. Design Medical students (na 96) and arts students (na 289) completed a baseline assessment including two multidimensional perfectionism scales. The medical students also completed measures of distress symptoms, personality (neuroticism, conscientiousness) and questions about their perceptions of their academic performance. Of the medical students, 58 completed a second set of questionnaires 6 months later (time 2).

Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide and longitudinal study

Abstract: Context Physicians show an increased prevalence of mental health problems, the first postgraduate years being particularly stressful. Objectives To study the prevalence of mental health problems during the fourth postgraduate year, and to investigate whether it is already possible to predict such problems at medical school. Subjects A cohort of medical students (n=396) from all Norwegian universities, who were approached in their graduating semester (baseline) and in their fourth postgraduate year. Methods A nationwide and longitudinal postal questionnaire survey, including measures of perceived mental health problems in need of treatment, personality, perceived stress and skills, and ways of coping. Data were analysed using logistic regression. Results Mental health problems in need of treatment during the fourth postgraduate year were reported by 17·2% (n=66), with no gender difference, possibly because of a higher prevalence among the men compared with the general population. A majority had not sought help. Univariate medical school predictors of mental health problems included: previous mental health problems; not being married/cohabitant; the personality traits ‘vulnerability’ (or neuroticism) and ‘reality weakness’; perceived medical school stress, and lack of perceived diagnostic skills. In addition, the coping variables avoidance, blamed self and wishful thinking were univariate predictors. Multivariate analysis identified the following adjusted predictors: previous mental health problems; ‘intensity’ (extraversion); perceived medical school stress, and wishful thinking. Medical school variables were inadequate for predicting which individual students would experience postgraduate mental health deterioration. However, the perceived medical school stress instrument may be used for selecting a subgroup of students suitable for group-oriented interventions.

Students' perception of medical school stress and their evaluation of a wellness elective.

Abstract: Context Because medical education is known to be demanding and stressful, Case Western Reserve University developed a programme which included a wellness elective which focused on stress reduction and personal wellness. Objectives The purpose of this study was to explore students’ perceptions of medical school stress and to assess their perspective on the wellness elective. Subjects The essays of 60 medical students enrolled in the wellness elective were used. Methods The essays were analysed using qualitative methodology. Results were validated by questionnaires mailed to the students 2 years later. Results It was found that the students felt that: (1) wellness issues should be important for physicians; (2) their own wellbeing had been diminished by the burden of information to be learned in medical school; (3) talking to peers was a useful coping mechanism, and (4) the elective gave permission to engage in wellness activities without additional guilt. Conclusions Based on the students’ responses, a wellness elective could be a useful addition to the first- or second-year medical curriculum.

Solving problems with group work in problem-based learning: hold on to the philosophy

Abstract: Introduction Problem-based learning (PBL) has gained a foothold within many schools in higher education as a response to the problems faced within traditional education. Discussion Working with PBL tutorial groups is assumed to have positive effects on student learning. Several studies provide empirical evidence that PBL stimulates cognitive effects and leads to restructuring of knowledge and enhanced intrinsic interest in the subject matter. However, staff members do not always experience the positive effects of group work which they had hoped for. When confronted with problems in group work, such as students who only maintain an appearance of being actively involved and students who let others do the work, teachers all too often implement solutions which can be characterized as teacherdirected rather than student-directed. Teachers tend to choose solutions which are familiar from their own experience during professional training, i.e. using the teacher-directed model. These solutions are not effective in improving group work and the negative experiences persist. Conclusion It is argued that teachers should hold on to the underlying educational philosophy when solving problems arising from group work in PBL, by choosing actions which are consistent with the student-directed view of education in PBL.

A framework for developing excellence as a clinical educator.

Abstract: The current emphasis on providing quality undergraduate and postgraduate medical education has focused attention on the educational responsibilities of all doctors. There is a greater awareness of the need to train doctors as educators and courses have been set up to satisfy this need. Some courses, such as those on how to conduct appraisal, are specific to one task facing a medical educator. Other courses take a broader view and relate educational theory to practice. In this paper we describe an outcome-based approach in which competence in teaching is defined in terms of 12 learning outcomes. The framework provides a holistic approach to the roles of the teacher and supports the professionalism of teaching. Such a framework provides the basis for the development of a curriculum for teaching excellence. It helps to define important competences for different categories of teachers, communicate the areas to be addressed in a course, identify gaps in course provision, evaluate courses, assist in staff planning and allow individuals to assess their personal learning needs. The framework is presented to encourage wider debate.

Barriers to breaking bad news among medical and surgical residents.

Abstract: Introduction Communicating ‘bad news’ to patients and their families can be difficult for physicians. Objective This qualitative study aimed to examine residents’ perceptions of barriers to delivering bad news to patients and their family members. Design Two focus groups consisting of first- and second-year medical and surgical residents were conducted to explore residents’ perceptions of the bad news delivery process. The grounded theory approach was used to identify common themes and concepts, which included: (1) guidelines to delivering bad news, (2) obstacles to delivering bad news and (3) residents’ needs. Setting McMaster University, Hamilton, Ontario, Canada. Subjects First- and second-year residents. Results Residents were able to identify several guidelines important to communicating the bad news to patients and their family members. However, residents also discussed the barriers that prevented these guidelines from being implemented in day-to-day practice. Specifically, lack of emotional support from health professionals, available time as well as their own personal fears about the delivery process prevented them from being effective in their roles. Residents relayed the need for increased focus on communication skills and frequent feedback with specific emphasis on the delivery of bad news. The residents in our study also stressed the importance of processing their own feelings regarding the delivery process with staff. Conclusions Although most residents realize important guidelines in the delivery of bad news, their own fears, a general lack of supervisory support and time constraints form barriers to their effective interaction with patients.

Learning to look: developing clinical observational skills at an art museum.

Abstract: Context Clinical diagnosis involves the observation, description, and interpretation of visual information. These skills are also the special province of the visual arts. We describe an educational collaboration between a medical school and an art museum, designed for the purpose of developing student skills in observation, description, and interpretation. Objectives In the programme, medical students first examine painted portraits, under the tutelage of art educators and medical school faculty. Then, the students examine photographs of patients’ faces and apply the same skills. Conclusion This programme, well-received by students and faculty, appeared to help the students not only in improving their empirical skills in observation, but also in developing increased awareness of emotional and character expression in the human face.

An outcomes research perspective on medical education: the predominance of trainee assessment and satisfaction

Abstract: Context A fundamental premise of medical education is that faculty should educate trainees, that is, students and residents, to provide high quality patient care. Yet, there is little research on the effect of medical education on patient outcomes. Objective A content analysis of leading medical education journals was performed to determine the primary foci of medical education research, using a three- dimensional outcomes research framework based on the paradigm of health services outcomes research. Data sources All articles in three medical education journals (Academic Medicine, Medical Education, and Teaching and Learning in Medicine) from 1996 to 1998 were reviewed. Papers presented at the Research in Medical Education conference at the Association of American Medical Colleges annual meeting during the same period, and published as Academic Medicine supplements, were also analysed. Study selection Only data-driven articles were selected for analysis; thus editorials and abstracts were excluded. Data extraction Each article was categorized according to primary participant (i.e. trainee, faculty, provider and patient), outcome (performance, satisfaction, professionalism and cost), and level of analysis (geographic, system, institution and individual(s)). Data synthesis A total of 599 articles were analysed. Trainees were the most frequent participants studied (68·9%), followed by faculty (19·4%), providers (8·1%) and patients (3·5%). Performance was the most common outcome measured (49·4%), followed by satisfaction (34·1%). Cost was the focus of only 2·3% of articles and patient outcomes accounted for only 0·7% of articles. Conclusions Medical education research is dominated by assessment of trainee performance followed by trainee satisfaction. Leading journals in medical education contain little information concerning the cost and products of medical education, that is, provider performance and patient outcomes. The study of these medical education outcomes represents an important challenge to medical education researchers.

Recent perspectives on clinical teaching.

Abstract: Clinical teaching is part of a doctor's professional life, whether it takes place in surgeries, clinics or in hospi- tals, with undergraduates, postgraduate trainees or colleagues. Learning to teach well means questioning the effectiveness of some of the old teaching methods, exploring new ideas and trying out new methods in different situations. It means collaborating more closely with colleagues and learners about developing and implementing new approaches to medical education. This paper is the AErst of an occasional series of articles about the practical aspects of clinical teaching. The articles have the following characteristics: they explore contemporary themes in medical and health care edu- cation; they use up-to-date references; they are a quick and easy resource for busy teachers; they explore new ideas about teaching and learning, and they provide a reference list of relevant papers. This article deals with recent ideas about clinical teachers' knowledge and roles, teaching and organizational strategies, and the measurement of teaching effectiveness.

Career obstacles for women in medicine: an overview.

Abstract: Purpose This article describes the current position of women in the field of medicine. Procedures Material was gathered using a MEDLINE search for recent articles on women’s career progress in medicine and data from the Association of American Medical Colleges. Main findings Although women now make up a large proportion of the medical student body in industrialized nations, they are still under-represented in a number of disciplines and in the higher echelons of medicine. A number of possible obstacles to career goals that presumably act synergistically include domestic responsibilities, rigidity in career structures and discrimination. Conclusions Organizations in the field of medicine can look to the business world for ‘best practices’ aimed at advancing women to incorporate in their own organization. Medical schools and other institutions are taking the issue seriously as can be seen from the variety of government and institution-based initiatives directed at improving the role of women in medicine.

A randomized, controlled, single‐blind trial of teaching provided by a computer‐based multimedia package versus lecture

Abstract: Background Computer-based teaching may alloweffective teaching of important psychiatric knowledgeand skills.Aims To investigate the effectiveness and acceptabilityof computer-based teaching.Method A single-blind, randomized, controlled study of166 undergraduate medical students at the Universityof Leeds, involving an educational intervention of eithera structured lecture or a computer-based teachingpackage (both of equal duration).Results There was no difference in knowledge betweenthe groups at baseline or immediately after teaching.Both groups made significant gains in knowledge afterteaching. Students who attended the lecture rated theirsubjective knowledge and skills at a statistically signifi-cantly higher level than students who had used thecomputers. Students who had used the computerpackage scored higher on an objective measure ofassessment skills. Students did not perceive the com-puter package to be as useful as the traditional lectureformat, despite finding it easy to use and recom-mending its use to other students.Conclusions Medical students rate themselves subject-ively as learning less from computer-based as comparedwith lecture-based teaching. Objective measures sug-gest equivalence in knowledge acquisition and signifi-cantly greater skills acquisition for computer-basedteaching.Keywords Education, medical/*methods; computerassistedinstruction/methods;*lectures;teaching/*meth-ods; education, medical, undergraduate; randomizedcontrolled trial; single-blind study; England.Medical Education 2001;35:847–854

The attitudes of 'tomorrow's doctors' towards mental illness and psychiatry: changes during the final undergraduate year.

Abstract: Aims To compare the efficacy of two teaching styles, didactic teaching and problem based learning, in producing enduring change in final-year medical students’ attitudes towards psychiatry and mental illness. Method A 1-year follow-up questionnaire survey of two groups of medical students taught psychiatry in their fourth-year training by two different methods. One-year follow-up scores were compared with pre-attachment and post-attachment scores in the fourth year. Results 70 (68%) students completed both questionnaires at follow-up. The follow-up scores were significantly lower compared with both the fourth-year pre-attachment and post-attachment scores, suggesting that the positive change in attitudes following psychiatric training in the fourth year significantly decayed during the final year. The two teaching methods did not differ in the magnitude of this reduction. Conclusions The positive change that occurs in medical students’ attitude towards psychiatry, psychiatrists and mental illness after their fourth-year psychiatric training is transient and decays over the final year.

The use of an objective structured clinical examination (OSCE) for formative and summative assessment in a general practice clinical attachment and its relationship to final medical school examination performance

Abstract: Objectives To report the use of OSCEs for both formative and summative purposes within a general practice undergraduate clinical attachment and to compare student performance in the departmental OSCEs with that of their final medical school examinations. Methods Twenty-eight students rotated through the attachment and undertook pre- and post-attachment OSCEs of similar format but different content. Results were analysed to determine relationships between mean scores in the two OSCEs and student performance in their final medical school MBBS examinations. Results There was a marked improvement in all OSCE station scores. Pre-attachment scores for those stations measuring physical examination and problem-solving skills were unrelated to prior clinical experience. Postattachment OSCE mean scores were significantly correlated with final examination OSCE and total mean scores. Conclusion The general practice attachment appears to upgrade those clinical skills measured by the pre- and post-attachment OSCE, however, there was no control group of students. Problem-solving and focused physical examination skills need to be targeted by all undergraduate clinical departments. The department’s post-attachment OSCE and total assessment results are predictors of final examination OSCE and total results. The use of pre- and post-attachment OSCEs facilitates both students’ formative learning processes and the department’s evaluation of its educational programme.

Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error.

Abstract: Introduction: There is a growing public perception that serious medical error is commonplace and largely tolerated by the medical profession. The Government and medical establishment's response to this perceived epidemic of error has included tighter controls over practising doctors and individual stick-and-carrot reforms of medical practice. Discussion: This paper critically reviews the literature on medical error, professional socialization and medical student education, and suggests that common themes such as uncertainty, necessary fallibility, exclusivity of professional judgement and extensive use of medical networks find their genesis, in part, in aspects of medical education and socialization into medicine. The nature and comparative failure of recent reforms of medical practice and the tension between the individualistic nature of the reforms and the collegiate nature of the medical profession are discussed. Conclusion: A more theoretically informed and longitudinal approach to decreasing medical error might be to address the genesis of medical thinking about error through reforms to the aspects of medical education and professional socialization that help to create and perpetuate the existence of avoidable error, and reinforce medical collusion concerning error. Further changes in the curriculum to emphasize team working, communication skills, evidence-based practice and strategies for managing uncertainty are therefore potentially key components in helping tomorrow's doctors to discuss, cope with and commit fewer medical errors.

Academic and non-academic predictors of success on the Nottingham undergraduate medical course 1970-1995.

Abstract: Objectives To identify academic and non-academic predictors of success of entrants to the Nottingham medical course over the first 25 completed years of the course’s existence. Setting, design and main outcome measures Retrospective study of academic and non-academic characteristics of 2270 entrants between 1970 and 1990, and their subsequent success. Analyses were undertaken of two cohorts (entrants between 1970 and 1985 and entrants between 1986 and 1990). Results Overall, 148 of 2270 (6·5%) entrants left the course, with the highest proportion being from the first 6 years (10·7%). Of the 148 leavers, 58 (39·2%) did so after obtaining their BMedSci degree. Concerning non-academic factors, in the 1970–85 cohort, applicants from the later years and those not taking a year out were more successful. However, these two factors had no influence on outcome in 1986–90. In contrast, ethnicity and gender were highly significant predictors of success in obtaining honours at BMBS in 1986–90 but at no other exam nor in the earlier years. Older, mature or graduate entrants were more successful at obtaining a first-class degree at BMedSci for the whole 21 years. However, they were less likely to be successful at passing the BMBS. With regard to academic factors, overall, A grades at Ordinary level/General Certificate of Secondary Education (O-Level/GCSE) were inconsistent independent predictors of success. However, for 1986–90, high grades at O-Level/GCSE chemistry and biology were strong independent predictors of success at BMedSci and BMBS. Very few Advanced level (A-Level) criteria were independent predictors of success for 1970–85. In contrast, for 1986–90 entrants, achieving a high grade at A-Level chemistry predicted success at obtaining a first-class degree at BMedSci, and a high grade at A-Level biology predicted success at BMBS. Over the 21 years, the majority of entrants achieved significantly lower grades at A-Level than predicted. General Studies A-Level was a poor predictor of achievement. Conclusions On balance our current GCSE A-grade requirements should remain. Biology should be added to Chemistry as a compulsory A-Level subject. If predicted A-Level grades are borderline then the lower estimate should be used. General Studies should continue not to be used in selection. Performance of more recent mature entrants at BMBS needs further study. The recent gender and ethnic biases in obtaining honours at BMBS is currently being examined. The motivation of applicants planning to take deferred entry should be carefully explored at interview.

The life long challenge of expertise.

Abstract: The development and maintenance of expertise in any domain requires extensive, sustained practice of the necessary skills. However, the quantity of time spent is not the only factor in achieving expertise; the quality of this time is at least as important. The development and maintenance of expertise requires extensive time dedicated specifically to the improvement of skills, an activity termed deliberate practise. Unfortunately, determining how to engage in this deliberate practise is not obvious for tasks such as diagnosis, which involve high stakes and are predominantly cognitive nature. Reflection on and adaptation of one’s cognitive processes is important; this could be supplanted by seeking out the opportunity to engage in trial and error in low risk environments such as simulators. Regardless, most individuals tend to favour well-entrenched activities and avoid practise. This may be due to lack of awareness of deficiencies in performance. However, it may also be due to the individual’s conception of the nature of expertise. Although expertise requires experience, experience alone is insufficient. Rather, the development of expertise is critically dependent on the individual making the most of that experience. As a result, motivational factors are fundamental to the development of expertise. Overcoming deficiencies in self-monitoring is not a sufficient remedy. It is also necessary is that clinicians form an attitude toward work that includes continual re-investment in improvement.

Identifying characteristics that students, interns and residents look for in their role models.

Abstract: Objective To identify characteristics which students, interns and residents look for in their role models Methods A 45-item self-administered questionnaire was sent to a sample (n=96, response rate 80%) consisting of three groups: (1) students in years 3–6 of the medical curriculum (n=66); (2) interns (n=17) and (3) residents (n=13) The questionnaire contained characteristics that participants might use to describe excellent role models, grouped under five general headings: personality, clinical, research and teaching skills, and community service Other characteristics mentioned by study subjects were qualitatively analysed using content analysis Results Personality and teaching and clinical skills were ranked as the top three factors, and research skills and community service as the least important factors by 79 (82%) respondents Qualitative analysis of characteristics described by respondents for their role models yielded 21 characteristics These were clustered into three main themes: role models as teacher, physician and person The most frequently mentioned characteristics were personal characteristics such as positive, respectful attitudes toward patients and their families, and staff and colleagues; honesty; politeness; enthusiasm; competence, and knowledge Females rated nine personal characteristics significantly higher than males (P < 0·05) Interns and residents valued teaching enthusiasm and competence significantly more than students (P=0·01) Role models had a strong influence on the specialty choice of 53 (55%) respondents Conclusion Knowing the characteristics of excellent role models should help medical educators to formulate strategies to recruit, retain and develop them Increasing exposure of a variety of excellent role models to aspiring medical practitioners should be encouraged

Measurement of clinical reflective capacity early in training as a predictor of clinical reasoning performance at the end of residency: an experimental study on the script concordance test.

Abstract: Background The script concordance (SC) test was conceived to measure knowledge organization, the presence of links between items of knowledge which allow for interpretation of data in clinical decision making situations. Earlier studies have shown that the SC test has good psychometric qualities and overcomes some of the limitations of simulation clinical testing. This study explores the predictive validity of the test. Objectives To verify whether scores obtained by students at the end of clerkship predict their clinical reasoning performance at the end of residency. Design Comparison of scores obtained on a SC test taken at the end of clerkship with those obtained 2 years later at the end of residency on two clinical reasoning assessments of known validity, called the short-answer management problems (SAMPs) and the simulated office orals (SOOs), and an objective structured clinical examination (OSCE) aimed at assessing hands-on skills and clinical reasoning. Data were treated by Pearson correlation analysis. Subjects and setting A cohort of 24 students from a medical school in Quebec was followed up to the end of their residency in family medicine, completed in several schools across Quebec. Results The observed Pearson correlation coefficients of the SC test were statistically significant (0AE451, Pa 0AE013; 0AE447; Pa 0AE015) when compared with the SAMPs and the SOOs, respectively. They were not statistically significant (0AE340, Pa 0AE052) when compared with the OSCE. Conclusion The authors assumed that the richness of knowledge organization, as indicated by SC test scores, would predict part of the performance on the measures of clinical reasoning (SAMP and SOO), but would predict less well performance on the OSCE which measures both clinical skills and clinical reasoning. Data found in the study are coherent with this hypothesis. This is evidence in favour of the construct validity of the SC test. It also indicates that, in the context of certification assessment, if a candidate has shown good organization of clinical knowledge at an early point in training, it can be expected that he/she will show good organization at subsequent measurements of this kind of knowledge. This appears to be true even if the later measures bear on a wider clinical domain.

Random comparison of 'virtual patient' models in the context of teaching clinical communication skills.

Abstract: Aims Two types of virtual patient designs can be distinguished: a ‘narrative’ structure and a ‘problem-solving’ structure. This study compares the same virtual patient with two different structures within the domain of communication skills. Methods Two virtual patients were constructed around the same case, one emphasizing a narrative and one a problem-solving model. Use of these packages was trialled with undergraduate medical students over 2 years. Students were randomly assigned to tutorials using the virtual patients, and their communication skills were compared with baseline performance by a separate group. Outcome was assessed by evaluation of an interview with a simulated patient. Results There was no significant difference between the three groups in overall communication skills. However there was a significant improvement in the communication skills of the narrative group when compared only with the problem-solving group. Additionally, various aspects of communication skills, such as use of open-ended questions and appropriate language, showed significant differences between the three groups. Conclusion There is some evidence to support the value of a narrative design for virtual patients which are to be used to teach communication skills, which encourages further investigation.

Using the Delphi technique to identify the cancer education requirements of general practitioners.

Abstract: Introduction Continuing education for the general practitioner (GP) is in need of revision. Much of today’s continuing education is based upon a traditional didactic approach, which is believed to be inappropriate and inefficient for the learning needs of the increasingly stretched GP. Objective To investigate the educational needs of a group of GPs, using the response to cancer to construct an appropriate model for the provision of care in general practice. Method The Delphi technique was adopted to reach ‘expert’ consensus.

Standardized or real patients to test clinical competence? The long case revisited

Abstract: Background In undergraduate clinical examinations, the use of real patients as long cases is being replaced by objective structured clinical examinations (OSCEs) which use simulated scenarios, although we lack published psychometric data on long cases to support the move from real to simulated patients. Aim To assess candidate performance across two history-taking long cases to estimate the number of cases required for a reliable assessment. Results are compared with psychometric data from an OSCE. Setting A final-year qualifying undergraduate clinical examination. Method Two observed history-taking long cases were included, alongside an OSCE. Candidates interviewed two unstandardized real patients. The history-taking part (14 minutes) was observed, uninterrupted, by examiner(s) who assessed data gathering, interviewing, and diagnostic and management skills. The presentation (7 minutes) was unstructured; the examiner(s) intervened as appropriate. Marks were expressed as a percentage of the total possible score and analysed using generalizability theory to estimate intercase reliability. Results Two examiner pairs independently rated both long cases for 79 (36·7%) of the 214 candidates. Projections based on generalizability theory showed that 10 20-minute cases would give reliabilities of 0·84 for single-marked and 0·88 for double-marked candidates, compared with a projected reliability of 0·73 for the same 214 candidates taking the OSCE. Conclusion If history-taking long cases are observed, three-and-a-half hours of testing time using 10 unstandardized patients would produce a reliable test. Long cases therefore are, in terms of reliability, no worse and no better than OSCEs in assessing clinical competence.

Impact of patient feedback on the interpersonal skills of general practice registrars: results of a longitudinal study

Abstract: Context A general practice vocational training program. Objectives To examine the impacts and implications of different models of systematic patient feedback on the development of general practice (GP) registrars’ interpersonal skills as they progressed through a GP vocational training program. Design A longitudinal study in which GP registrars were randomly assigned to three models of patient feedback: a control group and two intervention groups. The major source of data gathering was through the Doctors’ Interpersonal Skills Questionnaire (DISQ) which was administered to patients immediately after their consultation. Subjects 210 GP registrars, 104 GP supervisors and 28 156 patients. Results Multivariate analysis techniques (including repeated-measures analysis) tested the effectiveness of the interventions. Findings showed that systematic patient feedback at regular intervals throughout GP training resulted in sustained levels of interpersonal skills. The most significant gains in interpersonal skills for both intervention groups occurred in the earlier stages of general practice training. Most registrars found the experience of patient feedback useful for gaining a better understanding of their interpersonal skills and for identifying areas in which they needed to improve. GP supervisors valued the opportunity to receive patient feedback themselves and found the activity a useful adjunct to their preceptor role. Conclusions Patients, by providing feedback on doctors’ interpersonal skills, have been able to contribute to improving the quality of the patient–doctor interaction. GP registrars and their supervisors value highly the role of patient feedback in interpersonal skill development.

Patient-centred medicine through student-centred teaching: a student perspective on the key impacts of community- based learning in undergraduate medical education.

Abstract: Context The UK General Medical Council has proposed that increased use of community settings is essential to enhancement of medical education. However, such curriculum developments have been directed by educationalists and clinical faculty; there is to date little to show whether student perspectives accord with such expectations. Aim To examine student views on whether community-based learning during a UK undergraduate medical education course results in new learning in the areas expected, and to elucidate any process factors which enhance attainment of learning objectives. Method Nominal group technique, to develop consensus on important learning outcomes and process factors, and questionnaire survey, developed from the views of the nominal groups. Results 89 students participated (response rate 70% for the nominal groups, and 88% for questionnaire). Students perceived increased learning in many of the areas expected. In particular, students reported significant learning from: witnessing the impact of a longer term and more personal relationship with patients; the visible impact of social environment on health; the importance of dealing with people rather than diseases, and the use of the whole team for care. In addition, they emphasized that tutor, staff and patient enthusiasm for student presence and learning greatly enhanced the student learning experience. Conclusions Community settings appear to achieve the expected attitudinal adaptation of students. The role of the committed tutor and team is seen as pivotal to learning. The conclusions support an increased emphasis in contemporary medical education and related research activity on the key impact of relationships in the learning environment.

Effectiveness of basic clinical skills training programmes: a cross-sectional comparison of four medical schools

Abstract: Objective Training in physical diagnostic skills is an important part of undergraduate medical education. The objective of this study was to study the outcome of skills training at four medical schools. Context At the time of the study, three schools had a traditional lecture-based curriculum and one school had a problem-based learning curriculum with longitudinal skills training programme. All schools offer extended exposure to clerkships. Method A cross-sectional study in four medical schools was performed, using a written test of skills that has good correlation with actual student performance. The scores attained from four student groups were compared within and between the four medical schools. A total of 859 volunteer students from the later four years at each medical school participated in the study. Results The mean scores in the traditional medical schools increased with the start of skill training and the hands-on experience offered during the clerkships. Students from the school with the longitudinal skills training programme and the problem-based learning approach had significantly higher mean scores at the start of the clerkships, and maintained their lead in the subsequent clinical years. Conclusions Longitudinal skills training seems to offer the students a superior preparation for clerkships as well as influencing the students' learning abilities during the clerkships. The effect of the problem-based learning approach, also related to the innovative philosophy of the curriculum, could not be accounted for.

Stories as case knowledge: case knowledge as stories.

Abstract: Introduction Every case contains a human story of illness and a medical story of disease, which together cover person management, case management, health system management and self-management. Much of that management can be learned via a thorough set of stories of typical and atypical core cases compiled by clinical teachers. Stories provide a highly flexible framework for illustrating the lessons of experience, the tips and traps for young players, and the dilemmas requiring careful judgement in the trade-offs between benefits and risks. Listening to real stories unfold is much more fun than being lectured (and better remembered). Discussion Stories illustrate ‘what can happen’ in a case as a guide to ‘what to do’. A story begins with a real world situation with some predicament and a (causal) sequence of events or plot in which things are resolved one way or another. Patients tell their illness story; their clinician translates that into a disease story. Stories sort out what is important in such a predicament, consider the strategy and tactics of what to do, and speak about the outcomes. Each local situation provides relevance, context and circumstantial detail. Stories about case management can encapsulate practical knowledge, logical deduction, judgement and decision making, sharing with the student all the ingredients that develop expertise. Sometimes it is the plot that is important, sometimes the detail, sometimes it is the underlying message, the parable that resonates with the listener’s experiences and feelings.1 Stories can also accommodate the complexity of multiple variables and the influence of other stakeholders, the uncertainties and dilemmas within the trade-offs, and the niceties of ‘informed judgement’. Conclusion This paper makes four points. First, clinical stories recount pointed examples of ‘what happened’ that expand our expertise in handling ‘a case like that’. Second, cases are the unit of clinical work. Case stories expand the dimensions and details of case knowledge, case-based reasoning and case management. Carefully collated case stories can comprise the ‘real life’ clinical curriculum. Third, stories provide a framework for ‘web’ or ‘net’ thinking that links all the objective and subjective details within the multifaceted complexity of case management. Fourth, personal stories explain how both numerical and non-linear influences determined what decision was actually made in that case.

Do short cases elicit different thinking processes than factual knowledge questions do

Abstract: Purpose To assess whether case-based questions elicit different thinking processes from factual knowledge-based questions. Method 20 general practitioners (GPs) and 20 students solved case-based questions and matched factual knowledge-based questions while thinking aloud. Verbatim protocols were analysed. Five indicators were defined: extent of protocols; immediate responses; re-reading of information given in the stem or case after the question had been read; order of re-reading information, and type of consideration, i.e. ‘true–false’ type or ‘vector’, that is, a deliberation which has a magnitude and a direction. Results Cases elicited longer protocols than factual knowledge questions. Students re-read more given information than GPs. GPs gave an immediate response on twice as many occasions as students. GPs re-ordered the case information, whereas students re-read the information in the order it was presented. This ordering difference was not found in the factual knowledge questions. Factual knowledge questions mainly led to ‘true–false’ considerations, whereas cases elicited mainly ‘vector’ considerations. Conclusion Short case-based questions lead to thinking processes which represent problem-solving ability better than those elicited by factual knowledge questions.

Development and validation of a questionnaire to evaluate the effectiveness of evidence-based practice teaching.

Abstract: Aim The aim of this study was to develop and validate a questionnaire to evaluate the effectiveness of evidence-based practice (EBP) teaching Methods The 152 questionnaires completed by health care professionals with a range of EBP experience were used in this study Cronbach’s alpha for the knowledge and attitude questions indicated a satisfactory level of internal consistency (ie >0·60) Results The discriminative validity was evidenced by a statistically significant difference in the knowledge and attitude scores of ‘novices’ (ie little or no prior EBP education) compared with ‘experts’ (ie health care professionals and academics currently teaching EBP) Moderate to good (≥0·4) sensitivity index scores were observed for both knowledge and attitude scores as the result of comparing individuals before and after an EBP intervention Conclusions The results of this validation study indicate that the developed questionnaire is a satisfactory tool with which to evaluate the effectiveness of EBP teaching interventions