Showing papers in "Medical Education in 2005"

Stress and depression among medical students: a cross-sectional study

Abstract: Objective To assess the exposure to different stressors and the prevalence of depression among medical students at different levels of education, taking gender differences into account. Design Students were asked to complete a new stress inventory called the Higher Education Stress Inventory (HESI), the Major Depression Inventory (MDI), slightly modified, and questions on suicidal ideation developed by Meehan. Setting The study was carried out at the Karolinska Institute Medical University, Stockholm, Sweden. Matched controls from the general population were used. Participants All registered students in Years 1, 3 and 6 were enrolled in the study (n = 342). The response rate was 90.4%. Results Year 1 students gave high ratings to the workload and lack of feedback stressors. Year 3 students gave high ratings to ‘Worries about future endurance/competence’ and ‘Pedagogical shortcomings’. In Year 6, both the latter factors were rated highly, but Year 6 students also gave higher ratings than the 2 other groups to ‘Non-supportive climate’. In all 3 cohorts students complained of lack of feedback. Female students gave higher ratings than males to 4 out of 7 factors. Several stress factors were identified as being associated with depression. The prevalence of depressive symptoms among students was 12.9%, significantly higher than in the general population, and was 16.1% among female students versus 8.1% among males. A total of 2.7% of students had made suicide attempts, but none during the previous year. Conclusion Year 1 students indicated experiencing the highest degree of pressure from studies. A gender difference regarding stress levels was also seen, where women reported higher levels of stress than men. Medical students had higher depression rates than the general population, and women students had higher rates than men.

Assessing professional competence: from methods to programmes

Abstract: INTRODUCTION We use a utility model to illustrate that, firstly, selecting an assessment method involves context-dependent compromises, and secondly, that assessment is not a measurement problem but an instructional design problem, comprising educational, implementation and resource aspects. In the model, assessment characteristics are differently weighted depending on the purpose and context of the assessment. EMPIRICAL AND THEORETICAL DEVELOPMENTS Of the characteristics in the model, we focus on reliability, validity and educational impact and argue that they are not inherent qualities of any instrument. Reliability depends not on structuring or standardisation but on sampling. Key issues concerning validity are authenticity and integration of competencies. Assessment in medical education addresses complex competencies and thus requires quantitative and qualitative information from different sources as well as professional judgement. Adequate sampling across judges, instruments and contexts can ensure both validity and reliability. Despite recognition that assessment drives learning, this relationship has been little researched, possibly because of its strong context dependence. ASSESSMENT AS INSTRUCTIONAL DESIGN When assessment should stimulate learning and requires adequate sampling, in authentic contexts, of the performance of complex competencies that cannot be broken down into simple parts, we need to make a shift from individual methods to an integral programme, intertwined with the education programme. Therefore, we need an instructional design perspective. IMPLICATIONS FOR DEVELOPMENT AND RESEARCH Programmatic instructional design hinges on a careful description and motivation of choices, whose effectiveness should be measured against the intended outcomes. We should not evaluate individual methods, but provide evidence of the utility of the assessment programme as a whole.

Research in clinical reasoning: past history and current trends.

Abstract: Background Research in clinical reasoning has been conducted for over 30 years. Throughout this time there have been a number of identifiable trends in methodology and theory. Purpose This paper identifies three broad research traditions, ordered chronologically, are: (a) attempts to understand reasoning as a general skill − the ‘clinical reasoning' process; (b) research based on probes of memory − reasoning related to the amount of knowledge and memory; and (c) research related to different kinds of mental representations − semantic qualifiers, scripts, schemas and exemplars. Results and Conclusions Several broad themes emerge from this review. First, there is little evidence that reasoning can be characterised in terms of general process variables. Secondly, it is evident that expertise is associated, not with a single basic representation but with multiple coordinated representations in memory, from causal mechanisms to prior examples. Different representations may be utilised in different circumstances, but little is known about the characteristics of a particular situation that led to a change in strategy. Implications It becomes evident that expertise lies in the availability of multiple representations of knowledge. Perhaps the most critical aspect of learning is not the acquisition of a particular strategy or skill, nor is it the availability of a particular kind of knowledge. Rather, the critical element may be deliberate practice with multiple examples which, on the hand, facilitates the availability of concepts and conceptual knowledge (i.e. transfer) and, on the other hand, adds to a storehouse of already solved problems.

Problem-based learning: future challenges for educational practice and research.

Abstract: Context Problem-based learning (PBL) is widely used in higher education. There is evidence available that students and faculty are highly satisfied with PBL. Nevertheless, in educational practice problems are often encountered, such as tutors who are too directive, problems that are too well-structured, and dysfunctional tutorial groups. Purpose The aim of this paper is to demonstrate that PBL has the potential to prepare students more effectively for future learning because it is based on four modern insights into learning: constructive, self-directed, collaborative and contextual. These four learning principles are described and it is explained how they apply to PBL. In addition, available research is reviewed and the current debate in research on PBL is described. Discussion It is argued that problems encountered in educational practice usually stem from poor implementation of PBL. In many cases the way in which PBL is implemented is not consistent with the current insights on learning. Furthermore, it is argued that research on PBL should contribute towards a better understanding of why and how the concepts of constructive, self-directed, collaborative and contextual learning work or do not work and under what circumstances. Examples of studies are given to illustrate this issue.

What every teacher needs to know about clinical reasoning

Abstract: Context One of the core tasks assigned to clinical teachers is to enable students to sort through a cluster of features presented by a patient and accurately assign a diagnostic label, with the development of an appropriate treatment strategy being the end goal. Over the last 30 years there has been considerable debate within the health sciences education literature regarding the model that best describes how expert clinicians generate diagnostic decisions. Purpose The purpose of this essay is to provide a review of the research literature on clinical reasoning for frontline clinical teachers. The strengths and weaknesses of different approaches to clinical reasoning will be examined using one of the core divides between various models (that of analytic (i.e. conscious/controlled) versus non-analytic (i.e. unconscious/automatic) reasoning strategies) as an orienting framework. Discussion Recent work suggests that clinical teachers should stress the importance of both forms of reasoning, thereby enabling students to marshal reasoning processes in a flexible and context-specific manner. Specific implications are drawn from this overview for clinical teachers.

Entrustability of professional activities and competency‐based training

Abstract: The idea of competency-based training (CBT) seems to have entered medical education with a speed and impact that has outperformed problem-based learning in the 1980s and 1990s. Within less than 10 years, the CanMEDS competencies in Canada, the ACGME competencies in the United States and similar frameworks in other countries have been introduced for postgraduate medical training countrywide, and examples of competency-based undergraduate medical training have now begun to emerge. The growing number and impact of medical education journals and medical education conferences have helped in the spread of what could almost be called a ‘competencies hype’. It is likely that 2000–10 will be remembered as the decade of CBT in medical education. Competencybased training could remain in our memories as a lasting change that really advanced medical training. However, if we do not want to end up 10 years from now with the conclusion that a ‘competency’ was essentially nothing but a label, replacing what we conveniently used to call ‘educational objective’, it will now be necessary to specify its definition and translate it into daily practice. Signs of confusion about the concept of competency are already visible in the literature from fields other than medical education. The way in which we succeed in defining competencies, implement competency-based education and – most crucially ) assess competencies will be critical.

Making sense of focus groups

Abstract: CONTEXT: This paper provides an overview of the contribution of medical education research which has employed focus group methodology to evaluate both undergraduate education and continuing professional development. PRACTICALITIES AND PROBLEMS: It also examines current debates about the ethics and practicalities involved in conducting focus group research. It gives guidance as to how to go about designing and planning focus group studies, highlighting common misconceptions and pitfalls, emphasising that most problems stem from researchers ignoring the central assumptions which underpin the qualitative research endeavour. PRESENTING AND DEVELOPING FOCUS GROUP RESEARCH: Particular attention is paid to analysis and presentation of focus group work and the uses to which such information is put. Finally, it speculates about the future of focus group research in general and research in medical education in particular.

Proto-professionalism: how professionalisation occurs across the continuum of medical education.

Abstract: INTRODUCTION: Professionalism and its assessment across the medical education continuum have become prominent topics in recent years. We consider the nature of professionalism and how it emerges and relates to the work carried out by doctors and doctors-in-training. THESIS AND DISCUSSION: We suggest 6 domains in which evidence of professionalism can be expected: ethical practice; reflection/self-awareness; responsibility for actions; respect for patients; teamwork, and social responsibility. Furthermore, we propose that a defining characteristic is encapsulated by the Greek term phronesis, or practical wisdom. Phronesis is acquired only after a prolonged period of experience (and reflection on experience) occurring in concert with the professional's evolving knowledge and skills base. The prior period we have termed as one of 'proto-professionalism'. Influences on proto-professionalism are considered in terms of moral and psychosocial development and reflective judgement. CONCLUSION: Curricula that develop meta-skills will foster the acquisition and maintenance of professionalism. Adverse environmental conditions in the hidden curriculum may have powerful attritional effects.

Stories as data, data as stories: making sense of narrative inquiry in clinical education*

Abstract: BACKGROUND Narrative inquiry is a form of qualitative research that takes story as either its raw data or its product. Science and narrative can be seen as two kinds of knowing, reflected in the distinction between evidence-based medicine derived from population studies and narrative-based medicine focused upon the single case. A similar tension exists in the field of narrative inquiry between cognitiveorientated analytical methods and affective-orientated methods of synthesis. AIMS This paper aims to make sense of narrative inquiry in clinical education through definition of narrative, articulation of a typology of narrative research approaches, and critical examination in particular of analytical methods, the dominant approach in the literature. The typology is illustrated by research examples, and the role of medical education in developing expertise in narrative inquiry is discussed. An argument is made that the tension between analysis of the structure of stories and empathic use of stories can be seen as productive, stimulating expertise encompassing both approaches. DISCUSSION Analytical methods tend to lose the concrete story and its emotional impact to abstract categorisations, which may claim explanatory value but often remain descriptive. Stemming from discomfort with more integrative methods derived from the humanities, a science-orientated medical education may privilege analytical methods over approaches of synthesis. Medical education can redress this imbalance through attention to thinking with stories to gain empathy for a patient’s experience of illness. Such an approach can complement understanding of story as discourse ) how narratives may be used rhetorically to manage both social interactions and identity.

A review of evaluation outcomes of web-based continuing medical education.

Abstract: INTRODUCTION The Internet and worldwide web have expanded opportunities for the provision of a flexible, convenient and interactive form of continuing medical education (CME). Larger numbers of doctors are accessing and using the Internet to locate and seek medical information. It has been suggested that a significant proportion of this usage is directly related to questions that arise from patient care. A variety of Internet technologies are being used to provide both asynchronous and synchronous forms of web-based CME. Various models for designing and facilitating web-based CME learning have also been reported. The purpose of this study was to examine the nature and characteristics of the web-based CME evaluative outcomes reported in the peer-reviewed literature. METHODS A search of Medline was undertaken and the level of evaluative outcomes reported was categorised using Kirkpatrick’s model for levels of summative evaluation. RESULTS The results of this analysis revealed that the majority of evaluative research on web-based CME is based on participant satisfaction data. There was limited research demonstrating performance change in clinical practices and there were no studies reported in the literature that demonstrated that web-based CME was effective in influencing patient or health outcomes.

Conversation analysis, doctor–patient interaction and medical communication

Abstract: Introduction This paper introduces medical educators to the field of conversation analysis (CA) and its contributions to the understanding of the doctor−patient relationship. The conversation analysis approach Conversation analysis attempts to build bridges both to the ethnographic and the coding and quantitative studies of medical interviews, but examines the medical interview as an arena of naturally occurring interaction. This implies distinctive orientations and issues regarding the analysis of doctor−patient interaction. We discuss the CA approach by highlighting 5 basic features that are important to the enterprise, briefly illustrating each issue with a point from research on the medical interview. These features of conversation analytic theory and method imply a systematic approach to the organisation in interaction that distinguishes it from studies that rely on anecdote, ethnographic inquiry or the systematic coding of utterances. Conversation analysis and the medical interview We then highlight recent CA studies of the ‘phases’ of the internal medicine clinic and the implications of these studies for medical education. We conclude with suggestions for how to incorporate CA into the medical curriculum. It fits with biopsychosocial, patient-centred and relationship-centred approaches to teaching about medical communication.

Informal learning in postgraduate medical education: from cognitivism to 'culturism'.

Abstract: BACKGROUND Work-based learning occupies a central role in the training and ongoing development of the medical workforce. With this arises the need to understand the processes involved, particularly those relating to informal learning. Approaches to informal learning in postgraduate medical education have tended to consider the mind as an independent processor of information. METHOD In this paper, such cognitive approaches are critiqued and an alternative socio-cultural view on informal learning described. Recent and imminent changes in postgraduate medical education are identified, namely the reduction in patient experience, the fragmentation of teaching, and the development of competency frameworks and structured curricula. It is argued that although the latter may be useful in the construction of formal learning programmes, they will do little to enhance the progression of the individual from newcomer to old-timer or the cultural assimilation of the learner into a profession. DISCUSSION Strategies for enhancing informal learning in the workplace are recommended in which increased attention is paid to the development of the medical apprentice within a community of social practice. These include the establishment of strong goals, the use of improvised learning practices, attention to levels of individual engagement and workplace affordances, immersion in professional discourse and behaviours, support in relation to the development of a professional identity and the provision of opportunities to transform social practice.

Students' opinions about their preparation for clinical practice

Abstract: Introduction There are data that suggest that medical students do not feel sufficiently prepared for clinical practice in the clerkships. The transition from pre-clinical to clinical training causes problems. Objectives To seek quantitative verification of qualitative findings from an earlier focus group study on problems medical students encounter when entering the clinical phase of undergraduate training. Methods At the start of the clinical phase, all Year 4 students at Maastricht Medical School were surveyed on the transition from pre-clinical to clinical training and its effects on workload, knowledge, skills and learning. Results The response rate was 67%. Students were uncertain as to how to behave and act, mainly because they did not know what was expected of them. They experienced a drastic increase in workload and a lack of time for studying. They considered themselves to be moderately prepared with regard to knowledge and they regarded their physical examination skills as satisfactory. Students reported having difficulty applying theoretical knowledge in clinical practice and perceived shortcomings in basic science knowledge. In addition, they felt compelled to change their learning strategies. Discussion The results of this study confirm the findings of the focus group study. The students experienced problems related to professional socialisation and workload and deficiencies in knowledge and the organisation of knowledge. A good starting point for improvement may involve exploring students' suggestions of an extensive introduction into the clerkships, a more gradual transition with regard to workload and closer integration of pre-clinical and clinical education.

Conditions for successful reflective use of portfolios in undergraduate medical education.

Abstract: AIM: Portfolios are often used as an instrument with which to stimulate students to reflect on their experiences. Research has shown that working with portfolios does not automatically stimulate reflection. In this study we addressed the question: What are the conditions for successful reflective use of portfolios in undergraduate medical education? METHODOLOGY/RESEARCH DESIGN: We designed a portfolio that was aimed at stimulating reflection in early undergraduate medical education, using experiences described in the medical education literature and elsewhere. Conditions for reflective portfolio use were identified through interviews with 13 teachers (mentors), who were experienced in mentoring students in the process of developing their portfolios. The interviews were analysed according to the principles of grounded theory. RESULTS: The conditions for successful reflective use of portfolios that emerged from the interviews fell into 4 categories: coaching; portfolio structure and guidelines; relevant experiences and materials, and summative assessment. According to the mentors, working with a portfolio designed to meet these conditions will stimulate students' reflective abilities. CONCLUSION: This study shows that portfolios are a potentially valuable method of assessing and developing students' reflective skills in undergraduate medical training, provided certain conditions for effective portfolios are recognised and met. Portfolios have a strong potential for enhancing learning and assessment but they are very vulnerable and may easily lead to disappointment. Before implementing portfolios in education, one should first consider whether the necessary conditions can be fulfilled, including an appropriate portfolio structure, an appropriate assessment procedure, the provision of enough new experiences and materials, and sufficient teacher capacity for adequate coaching and assessment. © Blackwell Publishing Ltd 2005.

Perceptions of dissection by students in one medical school: beyond learning about anatomy. A qualitative study.

Abstract: Introduction The practice of dissection, as part of undergraduate medical education, has recently resurfaced in the public eye. This paper focuses on a number of important learning outcomes that were reported by Year 1–5 medical students in a British medical school, during the dissection sessions in the first 2 years of their training, as part of a wider qualitative research project into undergraduate medical education. Methods A group of 29 students was selected by quota sampling, using the whole student population of the medical school as the sampling frame. Qualitative data were collected by 1 : 1 interviews with students and from formal non-participatory observations of dissection sessions. Results Apart from learning to cope with the overt ‘emotional confrontation’ with the cadavers which assists anatomical learning, 7 additional covert learning outcomes were identified by the students: teamwork, respect for the body, familiarisation of the body, application of practical skills, integration of theory and practice, preparation for clinical work, and appreciation of the status of dissection within the history of medicine. Discussion A number of medical schools have either removed the practical, hands-on aspect of dissection in the medical undergraduate curriculum or are seriously considering such a measure, on financial and/or human resource grounds. This study highlights the fact that dissection can impart anatomical knowledge as well as offer other relevant, positive learning opportunities to enhance the skills and attitudes of future doctors.

Theme‐oriented discourse analysis of medical encounters

Abstract: APPROACH Theme-oriented discourse analysis looks at how language constructs professional practice. Recordings of naturally occurring interactions are transcribed and combined with ethnographic knowledge. Analytic themes drawn primarily from sociology and linguistics shed light on how meaning is negotiated in interaction. Detailed features of talk, such as intonation and choice of vocabulary, trigger inferences about what is going on and being talked about. These affect how interactants judge each other and decisions are made. Interactions also have larger rhetorical patterns used by both patients and doctors to persuade each other.

Faculty development for teaching and evaluating professionalism: from programme design to curriculum change

Abstract: INTRODUCTION The recent emphasis on the teaching and evaluation of professionalism for medical students and residents has placed significant demands on medicine’s educational institutions. The traditional method of transmitting professional values by role modelling is no longer adequate, and professionalism must be taught explicitly and evaluated effectively. However, many faculty members do not possess the requisite knowledge and skills to teach this content area and faculty development is therefore required. PROGRAMME DESCRIPTION A systematic, integrated faculty development programme was designed to support the teaching and evaluation of professionalism at our institution. The programme consisted of think tanks to promote consensus and buy-in, and workshops to convey core content, examine teaching strategies and evaluation methods, and promote reflection and self-awareness. PROGRAMME EVALUATION The programme was evaluated using a CIPP (context, input, process, product) analysis. The institution supported this initiative and local expertise was available. A total of 152 faculty members, with key educational responsibilities, attended 1 or more faculty development activities. Faculty participation resulted in agreement on the cognitive base and attributes of professionalism, consensus on the importance of teaching and evaluating professionalism, and self-reported changes in teaching practices. This initiative also led to the development of new methods of evaluation, site-specific activities and curriculum change. DISCUSSION A faculty development programme designed to support the teaching and evaluation of professionalism can lead to self-reported changes in teaching and practice as well as new educational initiatives. It can also help to develop more knowledgeable faculty members, who will, it is hoped, become more effective role models.

The case for educating health care students in professionalism as the core content of interprofessional education

Abstract: BACKGROUND: Professional teams are becoming more central to health care as evidence emerges that effective teamwork enhances the quality of patient care. Currently, health care professionals are poorly prepared by their education for their roles on the team. In parallel, there are increasing demands from consumers for health care professionals to serve the interests of society and patients through engaging in effective professional partnerships. Professionalism for health care providers is now being defined as a commitment to standards of excellence in the practice of the profession that are designed primarily to serve the interests of the patient and to be responsive to the health needs of society. Yet, there are multiple barriers impeding the development of professionalism beyond a uni-professional frame of reference. METHOD: Incorporating teamwork and professionalism into health care professional curricula at pre-registration level is proving to be challenging. These 2 areas of learning are brought together in this paper through a discussion of the role of interprofessional education in preparing all health care professional students for the workforce. CONCLUSION: Interprofessionalism is presented as a pre-registration curriculum framework that includes values shared by all health care professionals, which should be learned in order to more adequately prepare students for working in health care teams. It will be argued that interprofessional education provides appropriate methods by which to learn interprofessionalism, and that this will ultimately contribute to overcoming uni-professional exclusivity.

The use of qualitative research criteria for portfolio assessment as an alternative to reliability evaluation: a case study.

Abstract: Aim Because it deals with qualitative information, portfolio assessment inevitably involves some degree of subjectivity. The use of stricter assessment criteria or more structured and prescribed content would improve interrater reliability, but would obliterate the essence of portfolio assessment in terms of flexibility, personal orientation and authenticity. We resolved this dilemma by using qualitative research criteria as opposed to reliability in the evaluation of portfolio assessment. Methodology/research design Five qualitative research strategies were used to achieve credibility and dependability of assessment: triangulation, prolonged engagement, member checking, audit trail and dependability audit. Mentors read portfolios at least twice during the year, providing feedback and guidance (prolonged engagement). Their recommendation for the end-of-year grade was discussed with the student (member checking) and submitted to a member of the portfolio committee. Information from different sources was combined (triangulation). Portfolios causing persistent disagreement were submitted to the full portfolio assessment committee. Quality assurance procedures with external auditors were used (dependability audit) and the assessment process was thoroughly documented (audit trail). Results A total of 233 portfolios were assessed. Students and mentors disagreed on 7 (3%) portfolios and 9 portfolios were submitted to the full committee. The final decision on 29 (12%) portfolios differed from the mentor's recommendation. Conclusion We think we have devised an assessment procedure that safeguards the characteristics of portfolio assessment, with credibility and dependability of assessment built into the judgement procedure. Further support for credibility and dependability might be sought by means of a study involving different assessment committees.

Extracurricular research experience of medical students and their scientific output after graduation.

Abstract: graduation compared with peers without such experience. The subjects of this study were graduates (n ¼ 318) who were admitted for medical training in 1982 and 1983. Data concerning extracurricular research and articles published before graduation were collected by structured interviews in 1997 (n ¼ 274). Data concerning scientific output after graduation were gathered by a literature search in MEDLINE in 2002. The articles were traced by searching on author name and other clues such as publication year, co-authors and subject. Students who gained extracurricular research experience publish more articles after graduation (average ¼ 4 articles) than students without such experience (average ¼ 1 article). Of students who gained extracurricular research experience (n ¼ 103) approximately 50% (n ¼ 51) also published an article before graduation. The latter published an average of six articles after graduation compared to an average of two articles published after graduation by students who did not publish before graduation.

The value of basic science in clinical diagnosis: creating coherence among signs and symptoms.

Abstract: Background We investigated whether learning basic science mechanisms may have mnemonic value in helping students remember signs and symptoms, in comparison with learning the relation between symptoms and diagnoses directly. Purpose To compare 2 approaches to learning diagnosis: learning how features of various conditions relate to underlying pathophysiological mechanisms and learning the conditional probabilities of features and diseases. Methods Undergraduate students (n = 36) were taught 4 disorders (upper motor neuron lesion, lower motor neuron lesion, neuromuscular junction disease and muscular disease), either using basic science explanations or (symptom × disease) probabilities. They were tested with diagnostic cases immediately after learning and 1 week later. Results On the immediate test, there was no difference in the results. One week later, the accuracy of the mechanism group remained at 0.52, but the performance of the probability group had dropped to 0.43. Conclusions Knowledge of basic science may have value in clinical diagnosis by helping students recall or reconstruct the relationships between features and diagnoses.

Exploring family physicians' reactions to multisource feedback: perceptions of credibility and usefulness

Abstract: Purpose Physician performance is comprised of several domains of professional competence. Multisource feedback (MSF) or 360-degree feedback is an approach used to assess these, particularly the humanistic and relational competencies. Research studying responses to performance assessment shows that reactions vary and can influence how performance feedback is used. Improvement does not always result, especially when feedback is perceived as negative. This small qualitative study undertook preliminary exploration of physicians' reactions to MSF, and perceptions influencing these and the acceptance and use of their feedback. Methods We held focus groups with 15 family physicians participating in an MSF pilot study. Qualitative analyses included content and constant comparative analyses. Results Participants agreed that the purpose of MSF assessment should be to enhance practice and generally agreed with their patients' feedback. However, responses to medical colleague and co-worker feedback ranged from positive to negative. Several participants who responded negatively did not agree with their feedback nor were inclined to use it for practice improvement. Reactions were influenced by perceptions of accuracy, credibility and usefulness of feedback. Factors shaping these perceptions included: recruiting credible reviewers, ability of reviewers to make objective assessments, use of the assessment tool and specificity of the feedback. Conclusion Physicians' perceptions of the MSF process and feedback can influence how and if they use the feedback for practice improvement. These findings are important, raising the concern that feedback perceived as negative and not useful will have no or negative results, and highlight questions for further study.

Making sense of ethnography and medical education.

Abstract: Objective This paper aims to locate the ethnographic tradition in a socio-historical context. Method In this paper we chart the history of the ethnographic tradition, explaining its roots and highlighting its value in enabling the ethnographic researcher to explore and make sense of the otherwise invisible aspects of cultural norms and practices. We discuss a number of studies that have provided detailed and context-sensitive accounts of the everyday life of medical schools, medical practitioners and medical students. We demonstrate how the methods of ethnographic fieldwork offer ‘other ways of knowing’ that can have a significant impact on medical education. Conclusions The ethnographic research tradition in sociological and anthropological studies of educational settings is a significant one. Ethnographic research in higher education institutions is less common, but is itself a growing research strategy.

Active learning in a Year 2 pathology curriculum.

Abstract: PURP OSE Team- based learni ng (TBL) has beensucces sfully used in non-med ical curricula, but itseffecti veness in medi cal educati on has not beenstudied extensi vely. We evaluated the imp act of TBLon the academi c performa nce of Year 2 m edicalstude nts at Wrig ht State Universit y b y comp aring thisactive learni ng strategy aga inst a traditi onal m ethodof ca se-based group di scussion (CBGD ).MET HODS A prospec tive crosso ver design assigned83 Year 2 medical stud ents to either C BGD or TBLfor 8 p athology modu les in th e syste ms-b ased cur ri-culu m. The effecti veness of both learnin g methodswas assessed b y per formance on pathol ogy-base dexami nation question s con tained in end-of-co urseexami nations . The highest and low est aca demicquart iles of studen ts were evaluated sepa rately. Stu-dentsO opin ions of both methods were surveyed .RESU LTS No signiÞ cant differen ces in wh ole gro upperforma nce on path ology-base d exam ination ques-tions were observed as a consequ ence of experie n-cing TBL versus CBGD. However , studen ts in thelowes t aca demic quart ile showed better examinationperforma nce after exp erienci ng TBL than CBGD in 4of 8 modules (P ! 0.035 ). Students percei ved th atthe contr ibution s o f peers to learni ng were morehelp ful during TBL than CBGD (P ! 0.0 03).CONCLU SION This stud y demon strates that TBLand CBGD are equally effecti ve active learni ngstrateg ies when em ployed in a system s-based pre-clini cal pathol ogy curri culum , but stud ents with low-er aca demic per formance may ben eÞt more fromTBL than CBGD.KEYWO RDS hu mans; prospec tive studies; comp arat-ive study; path ology U *education ; *curricul um; tea ch-ing U *method s; *group pro cesses; clinicalcomp etence U *stand ards; edu cation , m edical, under -gradua te U *m ethods; cro ssover studies.Medical Educat ion 2005; 39 : 1045Ð 1055

Conducting ethnography in medical settings

Abstract: BACKGROUND Ethnographic research methods have a considerable history of use in medical settings. This paper provides a personal account of conducting ethnography in medical environments and focuses on some of the practical and ethical issues encountered in such settings. DISCUSSION AND CONCLUSION The paper describes particular issues that arise when undertaking ethnographic work, such as gaining access, recording data, research roles and researching elite groups, and recounts some of the dilemmas posed by doing this type of research in a medical setting. The paper concludes by reflecting on what ethnography might offer to medicine in return for the rich data medicine provides.

Use and misuse of Likert scales

Abstract: Editor – I read with some interest Dr Jamieson’s article on the uses and misuses of Likert scales. The issues of the appropriate statistical models for parametric (i.e. minimally interval) data and non-parametric (i.e. ordinal or categorical) data have been around for at least 50 years (Lord 1953). The real issue is not between analytical techniques, but in properly understanding the nature of the analyses, and the resulting inferences.

General competencies of problem-based learning (PBL) and non-PBL graduates.

Abstract: INTRODUCTION Junior doctors have reported shortcomings in their general competencies, such as organisational skills and teamwork. We explored graduates’ perceptions of how well their training had prepared them for medical practice and in general competencies in particular. We compared the opinions of graduates from problem-based learning (PBL) and non-PBL schools, because PBL is supposed to enhance general competencies.

Peer assessment of professional competence

Abstract: BACKGROUND Current assessment formats for medical students reliably test core knowledge and basic skills. Methods for assessing other important domains of competence, such as interpersonal skills, humanism and teamwork skills, are less well developed. This study describes the development, implementation and results of peer assessment as a measure of professional competence of medical students to be used for formative purposes. METHODS Year 2 medical students assessed the professional competence of their peers using an online assessment instrument. Fifteen randomly selected classmates were assigned to assess each student. The responses were analysed to determine the reliability and validity of the scores and to explore relationships between peer assessments and other assessment measures. RESULTS Factor analyses suggest a 2-dimensional conceptualisation of professional competence: 1 factor represents Work Habits and the other factor represents Interpersonal Habits, including respect and trustworthiness. The Work Habits factor had moderate, yet statistically significant correlations ranging from 0.21 to 0.53 with all other performance measures that were part of a comprehensive assessment of professional competence. Approximately 6 peer raters were needed to achieve a generalisability coefficient of 0.70. CONCLUSIONS Our findings suggest that it is possible to introduce peer assessment for formative purposes in an undergraduate medical school programme that provides multiple opportunities to interact with and observe peers.

The prediction of professional behaviour.

Abstract: Objective The purpose of this study was to establish outcome measures for professionalism in medical students and to identify predictors of these outcomes. Design Retrospective cohort study. Setting A US medical school. Participants All students entering in 1995 and graduating within 5 years. Measures Outcome measures included review board identification of professionalism problems and clerkship evaluations for items pertaining to professionalism. Pre-clinical predictor variables included material from the admissions application, completion of required course evaluations, students' self-reporting of immunisation compliance, students' performance on standardised patient (SP) exercises, and students' self-assessed performance on SP exercises. Results The outcome measures of clerkship professionalism scores were found to be highly reliable (alpha 0.88–0.96). No data from the admissions material was found to be predictive of professional behaviour in the clinical years. Using multivariate regression, failing to complete required course evaluations (B = 0.23) and failing to report immunisation compliance (B = 0.29) were significant predictors of unprofessional behaviour found by the review board in subsequent years. Immunisation non-compliance predicted low overall clerkship professional evaluation scores (B = − 0.34). Student self-assessment accuracy (SP score minus self-assessed score) (B = 0.03) and immunisation non-compliance (B = 0.54) predicted the internal medicine clerkship professionalism score. Conclusions This study identifies a set of reliable, context-bound outcome measures in professionalism. Although we searched for predictors of behaviour in the admissions application and other domains commonly felt to be predictive of professionalism, we found significant predictors only in domains where students had had opportunities to demonstrate conscientious behaviour or humility in self-assessment.

Current perspectives in assessment: the assessment of performance at work.

Abstract: Background Traditional assessment has improved significantly over the past 50 years. A number of new testing methods are now in place, the computer is improving both the fidelity and efficiency of examinations, and the psychometric principles on which assessment rests are more sophisticated than ever. Aim There is growing interest in quality improvement and there are increasing demands for public accountability. This has shifted the focus of testing from education to work. The purpose of this paper is to describe the assessment of work. Discussion In contrast to traditional assessment, there are no ‘methods’ for the evaluation of work because the content and difficulty of the examination are not controlled in any fashion. Instead it is a matter of identifying the basis for the judgements (outcomes, process, or volume), deciding how the data will be gathered (practice records, administrative databases, diaries/logs, or observation), and avoiding threats to validity and reliability (patient mix, patient complexity, attribution, and numbers of patients). Future directions Overall, the assessment of doctors' performance at work is in its infancy and much research and development is needed. Nonetheless, it is being used increasingly in programmes of continuous quality improvement and accountability. It is critical that refinements occur quickly to ensure that patients receive the highest quality of care and that doctors are treated fairly and provided with the information they need to guide their professional development.