Showing papers in "Medical Education in 2009"

Virtual patients: a critical literature review and proposed next steps.

Abstract: CONTEXT The opposing forces of increased training expectations and reduced training resources have greatly impacted health professions education. Virtual patients (VPs), which take the form of interactive computer-based clinical scenarios, may help to reconcile this paradox. METHODS We summarise research on VPs, highlight the spectrum of potential variation and identify an agenda for future research. We also critically consider the role of VPs in the educational armamentarium. RESULTS We propose that VPs' most unique and cost-effective function is to facilitate and assess the development of clinical reasoning. Clinical reasoning in experts involves a non-analytical process that matures through deliberate practice with multiple and varied clinical cases. Virtual patients are ideally suited to this task. Virtual patients can also be used in learner assessment, but scoring rubrics should emphasise non-analytical clinical reasoning rather than completeness of information or algorithmic approaches. Potential variations in VP design are practically limitless, yet few studies have rigorously explored design issues. More research is needed to inform instructional design and curricular integration. CONCLUSIONS Virtual patients should be designed and used to promote clinical reasoning skills. More research is needed to inform how to effectively use VPs.

Generational changes and their impact in the classroom: teaching Generation Me.

Abstract: RESULTS Today’s students (Generation Me) score higher on assertiveness, self-liking, narcissistic traits, high expectations, and some measures of stress, anxiety and poor mental health, and lower on self-reliance. Most of these changes are linear; thus the year in which someone was born is more relevant than a broad generational label. Moreover, these findings represent average changes and exceptions certainly occur.

Conceptual frameworks to illuminate and magnify.

Abstract: CONTEXT In a recent study of the quality of reporting experimental studies in medical education, barely half the articles examined contained an explicit statement of the conceptual framework used. Conceptual frameworks represent ways of thinking about a problem or a study, or ways of representing how complex things work. They can come from theories, models or best practices. Conceptual frameworks illuminate and magnify one's work. Different frameworks will emphasise different variables and outcomes, and their inter-relatedness. Educators and researchers constantly use conceptual frameworks to guide their work, even if they themselves are not consciously aware of the frameworks. METHODS Three examples are provided on how conceptual frameworks can be used to cast development and research projects in medical education. The examples are accompanied by commentaries and a total of 13 key points about the nature and use of conceptual frameworks. CONCLUSIONS Ultimately, scholars are responsible for making explicit the assumptions and principles contained in the conceptual framework(s) they use in their development and research projects.

The learning environment and medical student burnout: A multicentre study

Abstract: OBJECTIVES Little is known about specific personal and professional factors influencing student distress. The authors conducted a comprehensive assessment of how learning environment, clinical rotation factors, workload, demographics and personal life events relate to student burnout. METHODS All medical students (n = 3080) at five medical schools were surveyed in the spring of 2006 using a validated instrument to assess burnout. Students were also asked about the aforementioned factors. RESULTS A total of 1701 medical students (response rate 55%) completed the survey. Learning climate factors were associated with student burnout on univariate analysis (odds ratio [OR] 1.36-2.07; all P < or = 0.02). Being on a hospital ward rotation or a rotation requiring overnight call was also associated with burnout (ORs 1.69 and 1.48, respectively; both P < or = 0.02). Other workload characteristics (e.g. number of admissions) had no relation to student burnout. Students who experienced a positive personal life event had a lower frequency of burnout (OR 0.70; P < or = 0.02), whereas those who experienced negative personal life events did not have a higher frequency of burnout than students who did not experience a negative personal life event. On multivariate analysis personal characteristics, learning environment and personal life events were all independently related to student burnout. CONCLUSIONS Although a complex array of personal and professional factors influence student well-being, student satisfaction with specific characteristics of the learning environment appears to be a critical factor. Studies determining how to create a learning environment that cultivates student well-being are needed.

Repeated testing improves long‐term retention relative to repeated study: a randomised controlled trial

Abstract: Context Laboratory studies in cognitive psychology with relatively brief final recall intervals suggest that repeated retrieval in the form of tests may result in better retention of information compared with repeated study. Objectives Our study evaluates if repeated testing of material taught in a real-life educational setting (a didactic conference for paediatric and emergency medicine residents) replicates these findings when measured at a more educationally relevant final recall interval of 6 months. Methods Residents participated in an interactive teaching session on two topics: (i) status epilepticus, and (ii) myasthenia gravis. Residents were randomised to two counter-balanced groups which either took tests on status epilepticus and studied a review sheet on myasthenia gravis (SE-T/MG-S group) or took tests on myasthenia gravis and studied a review sheet on status epilepticus (MG-T/SE-S group). Testing and studying occurred immediately after teaching and then at two additional times at intervals of about 2 weeks. Residents received feedback after each test. Tests consisted of short-answer questions and the review sheets consisted of information identical to that on the answer sheets for the tests. At about 6 months residents took a final test on both topics. Results Nineteen residents in the SE-T/MG-S group and 21 residents in the MG-T/SE-S group completed the study. Collapsing across groups, repeated testing produced final test scores that were an average of 13% higher than those produced by repeated study (39% versus 26%) at > 6 months after the initial teaching session (t[78] = 3.93, standard error of the difference = 0.03, P < 0.001, d = 0.91). Conclusions Repeated testing with feedback appears to result in significantly greater long-term retention of information taught in a didactic conference than repeated, spaced study. Testing should be considered for its potential impact on learning and not only as an assessment device.

The effect of testing on skills learning.

Abstract: Objectives In addition to the extrinsic effects of assessment and examinations on students’ study habits, testing can have an intrinsic effect on the memory of studied material. Whether this testing effect also applies to skills learning is not known. However, this is especially interesting in view of the need to maximise learning outcomes from costly simulation-based courses. This study was conducted to determine whether testing as the final activity in a skills course increases learning outcome compared with an equal amount of time spent practising the skill. Methods We carried out a prospective, controlled, randomised, single-blind, post-test-only intervention study, preceded by a similar pre- and post-test pilot study in order to make a power calculation. A total of 140 medical students participating in a mandatory 4-hour in-hospital resuscitation course in the seventh semester were randomised to either the intervention or control group and were invited to participate in an assessment of learning outcome. The intervention course included 3.5 hours of instruction and training followed by 30 minutes of testing. The control course included 4 hours of instruction and training. Participant learning outcomes were assessed 2 weeks after the course in a simulated scenario using a checklist. Total assessment scores were compared between the two groups. Results Overall, 81 of the 140 students volunteered to participate. Learning outcomes were significantly higher in the intervention group (n = 41; mean score 82.8%, 95% confidence interval [CI] 79.4–86.2) compared with the control group (n = 40; mean score 73.3%, 95% CI 70.5–76.1) (P < 0.001). Effect size was 0.93. Conclusions Testing as a final activity in a resuscitation skills course for medical students increases learning outcome compared with spending an equal amount of time practising the skills.

Social accountability and accreditation: a new frontier for educational institutions

Abstract: CONTEXT An association with excellence should be reserved for educational institutions which verify that their actions make a difference to people's well-being. The graduates they produce should not only possess all of the competencies desirable to improve the health of citizens and society, but should also use them in their professional practice. Four principles enunciated by the World Health Organization refer to the type of health care to which people have a right, from both an individual and a collective standpoint: quality, equity, relevance and effectiveness. Therefore, social, economic, cultural and environmental determinants of health must guide the strategic development of an educational institution. DISCUSSION Social responsibility implies accountability to society for actions intended to serve it. In the health field, social accountability involves a commitment to respond as best as possible to the priority health needs of citizens and society. An educational institution should verify its impact on society by following basic principles of quality, equity, relevance and effectiveness, and by active participation in health system development. Its social accountability should be measured in three interdependent domains concerning health personnel: conceptualisation, production and utilisability. An educational institution that fully assumes the position of a responsible partner in the health care system and is dedicated to the public interest deserves a label of excellence. CONCLUSIONS As globalisation is reassessed for its social impact, societies will seek to justify their investments with more solid evidence of their impact on the public good. Medical schools should be prepared to be judged accordingly. There is an urgent need to foster the adaptation of accreditation standards and norms that reflect social accountability. Only then can educational institutions be measured and rewarded for their real capacity to meet the pressing health care needs of society.

Predictive validity of the multiple mini-interview for selecting medical trainees.

Abstract: INTRODUCTION In this paper we report on further tests of the validity of the multiple mini-interview (MMI) selection process, comparing MMI scores with those achieved on a national high-stakes clinical skills examination. We also continue to explore the stability of candidate performance and the extent to which so-called 'cognitive' and 'non-cognitive' qualities should be deemed independent of one another. METHODS To examine predictive validity, MMI data were matched with licensing examination data for both undergraduate (n = 34) and postgraduate (n = 22) samples of participants. To assess the stability of candidate performance, reliability coefficients were generated for eight distinct samples. Finally, correlations were calculated between 'cognitive' and 'non-cognitive' measures of ability collected in the admissions procedure, on graduation from medical school and 18 months into postgraduate training. RESULTS The median reliability of eight administrations of the MMI in various cohorts was 0.73 when 12 10-minute stations were used with one examiner per station. The correlation between performance on the MMI and number of stations passed on an objective structured clinical examination-based licensing examination was r = 0.43 (P < 0.05) in a postgraduate sample and r = 0.35 (P < 0.05) in an undergraduate sample of subjects who sat the MMI 5 years prior to sitting the licensing examination. The correlation between 'cognitive' and 'non-cognitive' assessment instruments increased with time in training (i.e. as the focus of the assessments became more tailored to the clinical practice of medicine). DISCUSSION Further evidence for the validity of the MMI approach to making admissions decisions has been provided. More generally, the reported findings cast further doubt on the extent to which performance can be captured with trait-based models of ability. Finally, although a complementary predictive relationship has consistently been observed between grade point average and MMI results, the extent to which cognitive and non-cognitive qualities are distinct appears to depend on the scope of practice within which the two classes of qualities are assessed.

Using mixed methods research in medical education: basic guidelines for researchers

Abstract: CONTEXT Mixed methods research involves the collection, analysis and integration of both qualitative and quantitative data in a single study. The benefits of a mixed methods approach are particularly evident when studying new questions or complex initiatives and interactions, which is often the case in medical education research. Basic guidelines for when to use mixed methods research and how to design a mixed methods study in medical education research are not readily available. METHODS The purpose of this paper is to remedy that situation by providing an overview of mixed methods research, research design models relevant for medical education research, examples of each research design model in medical education research, and basic guidelines for medical education researchers interested in mixed methods research. CONCLUSIONS Mixed methods may prove superior in increasing the integrity and applicability of findings when studying new or complex initiatives and interactions in medical education research. They deserve an increased presence and recognition in medical education research.

Cultural competence: a conceptual framework for teaching and learning.

Abstract: Objectives The need to address cultural and ethnic diversity issues in medical education as a means to improve the quality of care for all has been widely emphasised. Cultural competence has been suggested as an instrument with which to deal with diversity issues. However, the implementation of culturally competent curricula appears to be difficult. We believe the development of curricula would profit from a framework that provides a practical translation of abstract educational objectives and that is related to competencies underlying the medical curriculum in general. This paper proposes such a framework. Methods The framework illustrates the following cultural competencies: knowledge of epidemiology and the differential effects of treatment in various ethnic groups; awareness of how culture shapes individual behaviour and thinking; awareness of the social context in which specific ethnic groups live; awareness of one’s own prejudices and tendency to stereotype; ability to transfer information in a way the patient can understand and to use external help (e.g. interpreters) when needed, and ability to adapt to new situations flexibly and creatively. Discussion The framework indicates important aspects in taking care of an ethnically diverse patient population. It shows that there are more dimensions to delivering high-quality care than merely the cultural. Most cultural competencies emphasise a specific aspect of a generic competency that is of extra importance when dealing with patients from different ethnic groups. We hope our framework contributes to the further development of cultural competency in medical curricula.

Sociological interpretations of professionalism

Abstract: CONTEXT Professionalism is a hot topic in medical education, yet there is debate about what professionalism actually is. The reason is that medical educators primarily frame professionalism as a list of characteristics or behaviours. However, many sociologists of the professions favour more explanatory theories that incorporate political, economic and social dimensions into understanding of the nature and function of professionalism. OBJECTIVES This paper reviews a range of approaches used in the sociology of the professions to support the argument that medical education needs to reframe its priorities for research into, and the development of, professionalism in medical education. METHODS The literature on the sociology of the professions was reviewed and summarised in relation to medical education. CONCLUSIONS A focus on individual characteristics and behaviours alone is insufficient as a basis on which to build further understanding of professionalism and represents a shaky foundation for the development of educational programmes and tools. Contemporary sociological literature on professionalism should have greater prominence in this domain.

A systematic review of resident-as-teacher programmes

Abstract: CONTEXT Residents in all disciplines serve as clinical teachers for medical students. Since the 1970s, there has been increasing evidence to demonstrate that residents wish to teach and that they respond positively to formal teacher training. Effective resident-as-teacher (RaT) programmes have resulted in improved resident teaching skills. Current evidence, however, is not clear about the specific features of an effective RaT programme. OBJECTIVES This study was performed in order to investigate the effectiveness of RaT programmes on resident teaching abilities and to identify the features that ensure success. Methods of assessment used to ascertain the effectiveness of RaT programmes are also explored. METHODS The literature search covered the period between 1971 and 2008. Articles focusing on improving resident teaching skills were included. Each study was reviewed by two reviewers and data were collected using a standard abstraction summary sheet. Study outcomes were graded according to a modified Kirkpatrick's model of educational outcomes. RESULTS Twenty-nine studies met review inclusion criteria. Interventions included workshops, seminars, lectures and teaching retreats. Twenty-six studies used a pre- and post-intervention outcome comparison method. Subjective outcome measures included resident self-evaluation of teaching skills or evaluation by medical students, peers and faculty members. Objective outcome measures included written tests, evaluation of teaching performance by independent raters and utilisation of objective structured teaching examinations. One study objectively measured learning outcomes at the level of medical students, utilising the results of an objective structured clinical examination. Overall resident satisfaction with RaT programmes was high. Participants reported positive changes in attitudes towards teaching. Participant knowledge of educational principles improved. Study methodologies allowed for significant risks of bias. CONCLUSIONS More rigorous study designs and the use of objective outcome measures are needed to ascertain the true effectiveness of RaT programmes. Future research should focus on determining the impact of RaT programmes on learning achievement at the level of medical students.

Strategies and interventions for the involvement of real patients in medical education: a systematic review.

Abstract: OBJECTIVES There is increasing emphasis on encouraging more active involvement of patients in medical education. This is based on the recognition of patients as 'experts' in their own medical conditions and may help to enhance student experiences of real-world medicine. This systematic review provides a summary of evidence for the role and effectiveness of real patient involvement in medical education. METHODS MEDLINE, EMBASE, ERIC, PsychINFO, Sociological Abstracts and CINAHL were searched from the start of the databases to July 2007. Three key journals and reference lists of existing reviews were also searched. Articles published in English and reporting primary empirical research on the involvement of real patients in medical education were included. The synthesis of findings is integrated by narrative structured in such a way to address the research questions. RESULTS A total of 47 articles were included in the review. The majority of studies reported patients in the role of teachers only; others described patient involvement in assessment or curriculum development or in combined roles. Patient involvement was recommended in order to bring the patient voice into education. There were several examples of how to recruit and train patients to perform an educational role. The effectiveness of patient involvement was measured by evaluation studies and reported improvements in skills. CONCLUSIONS There was limited evidence of the long-term effectiveness of patient involvement and issues of ethics, psychological impact and influence on education policy were poorly explored. Future studies should address these issues and should explore the practicalities of sustaining such educational programmes within medical schools.

Peer-assisted versus faculty staff-led skills laboratory training: a randomised controlled trial.

Abstract: Objectives Although peer-assisted learning (PAL) is widely employed throughout medical education, its effectiveness for training in technical procedures in skills laboratories has been subject to little systematic investigation. We conducted a prospective, randomised trial to evaluate the hypotheses that PAL is effective in technical skills training in a skills laboratory setting, and PAL is as effective as faculty staff-led training. Methods Volunteer Year 3 medical students were randomly assigned to one of three groups. Two of these received regular skills training from either cross-year peer tutors or experienced faculty staff. Following training, both groups were assessed using an objective structured clinical examination (OSCE) (three stations assessing various injection techniques) which was video-recorded. Two independent video assessors scored the OSCEs using binary checklists and global ranking forms. A third student group was assessed prior to training and served as a control group. Results A total of 89 students (mean age 23.0 ± 0.2 years; 41 male, 48 female) agreed to participate in the trial. Confounding variables including prior training as a paramedic or previous experience in performing the technical procedures did not significantly differ between the three study groups. In the OSCE, PAL (58.1 ± 1 binary points, 4.9 ± 0.1 global ranking points) and faculty-led groups (58.3 ± 1 binary points, 4.7 ± 0.1 global ranking points) scored significantly higher than the control group (33.3 ± 1 binary points, 2.7 ± 0.1 global ranking points; all P < 0.0001). There was no significant difference between the PAL and faculty-led groups (P = 0.92 for binary checklists, P = 0.11 for global rankings). Conclusions Peer-assisted learning is a successful method for learning technical procedures in a skills laboratory setting and can be just as effective as the training provided by experienced faculty staff.

Electives: isn't it time for a change?

Abstract: Objectives Medical student electives are memorable learning experiences, of which approximately 40% are spent in developing countries. Students often have laudable motivation but are rarely helped to learn most effectively or contribute meaningfully whilst away. Each year an estimated 350 years of elective time is spent in developing countries (by students from the UK alone), which represents substantial opportunity. Methods We conducted a literature search prior to developing an alternative approach towards electives based upon educational and ethical principles. Results Despite their anecdotal value there has been little empirical research conducted into electives. From our review we identified four key learning domains (Clinical Knowledge and Skills, Attitudes, Global Perspectives, Personal and Professional Development) and two broader issues (Institutional Benefits and Moral/Ethical Considerations). Potentially beneficial and more structured alternatives are emerging and improvements appear possible through institutional collaborations and greater planning in order to maximise the educational experience, opportunities to contribute and minimise the risks involved in electives. Conclusions Electives are a highlight of clinical training but probably often represent missed opportunities. There are both educational and moral reasons for seeking more considered approaches to reduce the ‘medical tourism’ that can result from the current largely ad hoc arrangements.

'It's a cultural expectation...' The pressure on medical trainees to work independently in clinical practice.

Abstract: Context Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory-based approaches to the implications for patient safety of this pressure towards independent working. Methods In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. Results Participants conceived that the pressure towards independence in clinical work originated in trainees’ desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. Discussion The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger’s situated learning theory suggests that giving attention to the ‘independent doctor’ ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al.’s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high-stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory-based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety.

Assessment not only drives learning, it may also help learning

Abstract: There is considerable research in cognitive psychology which could provide guidance to medical education researchers and teachers, but which is often ignored because it can be difficult to generalise results from the material or tasks commonly used in psychology laboratories to medical education. It was with great interest, therefore, that I read an article on testenhanced learning, by Larsen, Butler and Roediger, in the October issue of Medical Education. I was then asked to comment on a related article in this issue of the journal that demonstrates the phenomenon in a clinical teaching setting. Larsen et al. described a line of research from cognitive psychology called the ‘testing effect’, which had been applied to both laboratory and educationbased contexts. They were forced to conclude simply with a discussion of its potential implications for medical education. The Kromann et al. paper, in this issue of the journal, suggests that some of that potential can be realised.

Doctor scores on national qualifying examinations predict quality of care in future practice

Abstract: OBJECTIVESThis study aimed to determine if national licensing examinations that measure medical knowledge (QE1) and clinical skills (QE2) predict the quality of care delivered by doctors in future practice.METHODSCohorts of doctors who took the Medical Council of Canada Qualifying Examinations Part

Computer animations in medical education: A critical literature review

Abstract: Context Animations can depict dynamic changes over time and location, and illustrate phenomena and concepts that might otherwise be difficult to visualise. However, animations may not always be effective and educators who use animations must understand the principles that govern their use. Objectives This review aims to illustrate potential applications of animations in medical education, to identify evidence-based principles for their design and use, and to propose an agenda for future research. Methods We searched MEDLINE, PsychINFO and EMBASE for articles describing the use of computer animations in medical education. We reviewed and summarised all identified original research studies comparing animations with an alternative computer-based or non-computer-based format. We also selectively reviewed non-medical education research on the use of computer animations. Results Medical educators have used animations in a variety of computer-assisted learning applications, but few comparative studies have been published and the evidence is inconclusive. Research outside medical education shows conflicting results for studies comparing animations with static images. This may reflect differences in cognitive load induced by animation, or differences in the type of motion being illustrated. The benefits of animations may also vary according to learner characteristics such as prior knowledge and spatial ability. Features of animation that appear to facilitate learning include permitting learner control over the animation’s pace, allowing learners to interact with animations and splitting the animation activity into small chunks (segmenting). Conclusions Existing medical education research does little to inform the use of animations. Research is needed to confirm and extend non-medicine research to ascertain when to use animations and how to use them effectively.

Assessment of competence and progressive independence in postgraduate clinical training

Abstract: CONTEXT: At present, competency-based, outcome-focused training is gradually replacing more traditional master-apprentice teaching in postgraduate training. This change requires a different approach to the assessment of clinical competence, especially given the decisions that must be made about the level of independence allowed to trainees. METHODS: This study was set within postgraduate obstetrics and gynaecology training in the Netherlands. We carried out seven focus group discussions, four with postgraduate trainees from four training programmes and three with supervisors from three training programmes. During these discussions, we explored current opinions of supervisors and trainees about how to determine when a trainee is competent to perform a clinical procedure and the role of formal assessment in this process. RESULTS: When the focus group recordings were transcribed, coded and discussed, two higher-order themes emerged: factors that determine the level of competence of a trainee in a clinical procedure, and factors that determine the level of independence granted to a trainee or acceptable to a trainee. CONCLUSIONS: From our study, it is evident that both determining the level of competence of a trainee for a certain professional activity and making decisions about the degree of independence entrusted to a trainee are complex, multi-factorial processes, which are not always transparent. Furthermore, competence achieved in a certain clinical procedure does not automatically translate into more independent practice. We discuss the implications of our findings for the assessment of clinical competence and provide suggestions for a transparent assessment structure with explicit attention to progressive independence.

How effective is self‐guided learning of clinical technical skills? It’s all about process

Abstract: Objectives Mounting evidence suggests that trainees acquire psychomotor skills better when they are allowed self-guided access to instructional material and when they set goals that are related to performance processes rather than performance outcomes. The present study assessed whether self-guided access to instruction and the setting of process goals lead to better acquisition of clinical technical skills. Methods To learn wound closure skills, 48 medical students were randomly assigned to one of four groups in a 2 × 2 study design. Self-guided participants were able to access the instructional video freely, whereas control participants were restricted to watching only those video segments accessed by their matched self-guided participant. Each group was further divided into two subgroups, comprising a process goal subgroup, where participants set goals focused on performance mechanisms, and an outcome goal subgroup, where participants set goals focused on performance products. Performance on pre-, post-, retention and transfer tests was assessed with hand motion measures and expert evaluations. Group differences were evaluated using one-way anovas. Results The self-guided group with process goals showed greater skill retention than its matched control group, whereas the self-guided group with outcome goals did not. Furthermore, the groups with process goals performed better on the transfer test than the outcome goal groups. Outcome goal participants accessed the instructional video most frequently. Conclusions Our findings advance the study of independent learning in medical education. Trainees used interactive and structured instructional materials to effectively self-guide their learning of clinical technical skills. However, a self-guided benefit was demonstrated only when trainees set process goals.

Feedback by simulated patients in undergraduate medical education: a systematic review of the literature.

Abstract: Objectives Although the importance of feedback by simulated patients (SPs) is generally recognised, knowledge is scarce about the most effective ways in which SPs can provide feedback. In addition, little is known about how SPs are trained to provide feedback. This study aimed to provide a systematic overview of the ways in which SPs provide feedback to undergraduate medical students, the domains in which SPs provide feedback and the ways in which SPs are trained to provide feedback. Methods We performed a systematic search of the literature using PubMed, PsychINFO and ERIC and searched for additional papers cited in reference lists. Papers were selected on the basis of pre-established inclusion and exclusion criteria and were classified, using a pre-established form, according to three aspects of SP feedback: training in giving feedback; the process of delivering feedback, and the domain(s) in which feedback is given. Results A total of 49 studies were included and described in detail on the basis of the three aspects of SP feedback described above. The ways in which SPs were trained to give feedback were largely heterogeneous, as were the processes by which feedback was provided by SPs. Only a few studies described feedback processes that were in accordance with general recommendations for the delivery of effective feedback. Although feedback from the patient’s perspective is generally recommended, most SPs provided feedback on clinical skills and communication skills. Discussion There appear to be no clear standards with regard to effective feedback training for SPs. Furthermore, the processes by which feedback is provided by SPs and the selection of domain(s) in which SPs give feedback often seem to lack a solid scientific basis. Suggestions for further research are provided.

When only the real thing will do: junior medical students’ learning from real patients

Abstract: Bell, K., Boshuizen, H. P. A., Scherpbier, A. J. J. A., & Dornan, T. L. (2009). When only the real thing will do: junior medical students' learning from real patients. Medical Education, 43(11), 1036-1043. doi:10.1111/j.1365-2923.2009.03508.x

Universal problems during residency: abuse and harassment.

Abstract: Objectives Perceived abuse or harassment during residency has a negative impact on residents’ health and well-being. This issue pertains not only to Western countries, but also to those in Asia. In order to launch strong international preventive measures against this problem, it is necessary to establish the generality and cultural specificity of this problem in different countries. Therefore, we investigated mistreatment among resident doctors in Japan. Methods In 2007, a multi-institutional, cross-sectional survey was conducted at 37 hospitals. A total of 619 residents (409 men, 210 women) were recruited. Prevalence of mistreatment in six categories was evaluated: verbal abuse; physical abuse; academic abuse; sexual harassment; gender discrimination, and alcohol-associated harassment. In addition, alleged abusers, the emotional effects of abusive experiences, and reluctance to report the abuse to superiors were investigated. Male and female responses were statistically compared using chi-square analysis. Results A total of 355 respondents (228 men, 127 women) returned a completed questionnaire (response rate 57.4%). Mistreatment was reported by 84.8% of respondents (n = 301). Verbal abuse was the most frequently experienced form of mistreatment (n = 256, 72.1%), followed by alcohol-associated harassment (n = 184, 51.8%). Among women, sexual harassment was also often reported (n = 74, 58.3%). Doctors were most often reported as abusers (n = 124, 34.9%), followed by patients (n = 77, 21.7%) and nurses (n = 61, 17.2%). Abuse was reported to have occurred most frequently during surgical rotations (n = 98, 27.6%), followed by rotations in departments of internal medicine (n = 76, 21.4%), emergency medicine (n = 41, 11.5%) and anaesthesia (n = 40, 11.3%). Very few respondents reported their experiences of abuse to superiors (n = 36, 12.0%). The most frequent emotional response to experiences of abuse was anger (n = 84, 41.4%). Conclusions Mistreatment during residency is a universal phenomenon. Deliberation on the occurrence of this universally wrong tradition in medical culture will lead to the establishment of strong preventive methods against it. Current results indicate that alcohol-associated harassment during residency is a Japanese culture-specific problem and effective preventive measures against this are also urgently required.

Comparison of trait and ability measures of emotional intelligence in medical students

Abstract: Context Emotional intelligence (EI), the ability to perceive emotions in the self and others, and to understand, regulate and use such information in productive ways, is believed to be important in health care delivery for both recipients and providers of health care. There are two types of EI measure: ability and trait. Ability and trait measures differ in terms of both the definition of constructs and the methods of assessment. Ability measures conceive of EI as a capacity that spans the border between reason and feeling. Items on such a measure include showing a person a picture of a face and asking what emotion the pictured person is feeling; such items are scored by comparing the test-taker’s response to a keyed emotion. Trait measures include a very large array of non-cognitive abilities related to success, such as self-control. Items on such measures ask individuals to rate themselves on such statements as: ‘I generally know what other people are feeling.’ Items are scored by giving higher scores to greater self-assessments. We compared one of each type of test with the other for evidence of reliability, convergence and overlap with personality. Methods Year 1 and 2 medical students completed the Meyer–Salovey–Caruso Emotional Intelligence Test (MSCEIT, an ability measure), the Wong and Law Emotional Intelligence Scale (WLEIS, a trait measure) and an industry standard personality test (the Neuroticism–Extroversion–Openness [NEO] test). Results The MSCEIT showed problems with reliability. The MSCEIT and the WLEIS did not correlate highly with one another (overall scores correlated at 0.18). The WLEIS was more highly correlated with personality scales than the MSCEIT. Conclusions Different tests that are supposed to measure EI do not measure the same thing. The ability measure was not correlated with personality, but the trait measure was correlated with personality.

Relative effectiveness of high- versus low-fidelity simulation in learning heart sounds.

Abstract: Context Although there are increasing numbers of studies of outcomes of high-fidelity patient simulators, few contrast their instruction with that provided by equivalent low-fidelity, inexpensive simulators. Further, examination of decays in learning and application (transfer) to real patient problems is rare. In this study, we compared the effects of training using a high-fidelity heart sound simulator (Harvey) and a low-fidelity simulator (a CD) on recognition of both simulated heart sounds and those in actual patients. Methods A pilot study with 10 students was conducted to show the feasibility of the methods and some evidence of modality-specific learning (the Harvey-trained group scored 72% correct on Harvey and 36% correct on CD test examples; the CD-trained group scored 60% correct on both CD and Harvey test examples). A main study was then initiated involving 37 Year 3 medical students from the University of Leeds. They received 1 hour of common instruction, after which one group received 3 hours of specific instruction on Harvey. The second group received 3 hours of instruction using a CD. Six weeks later, both groups were tested blind with real patients with stable heart sounds. Stations were observed by an examiner who scored communication skills and examination skills using 5-point scales. Results The Harvey-trained group was slightly but not significantly better than the CD-trained group at identifying heart sounds (3.11 versus 2.47, respectively; P = 0.06). However, there was no difference between the Harvey and CD-trained groups in diagnosis (2.94 versus 2.84, respectively), communication skills (18.9 versus 19.6, respectively) or examination skills (17.4 versus 17.5, respectively). Conclusions The study found little evidence that students trained with a high-fidelity simulator were more able to transfer skills to real patients than a control group. Although there was some suggestion that the Harvey-trained group was better at recognising heart sounds, there was no difference between groups in diagnostic accuracy or clinical skills.

Emotional intelligence in medical students: does it correlate with selection measures?

Abstract: Context Much attention and emphasis are placed on the selection of medical students. Although selection measures have been validated in the literature, it is not yet known whether high scores at selection are indicative of high levels of interpersonal aptitude. Emotional intelligence (EI) is reported to be a predictor of the interpersonal and communications skills medical schools are looking for in applicants. Objectives This study describes EI scores in medical students and explores correlations between EI and selection scores at the University of Western Australia. Methods Senior medical students from a 6-year undergraduate curriculum completed the online MSCEIT® (Mayer–Salovey–Caruso Emotional Intelligence Test) survey. Scores for EI were described and correlations between EI and Undergraduate Medicine and Health Sciences Admission Test (UMAT), Interview and Tertiary Entrance Rank (TER) scores were analysed. Results Mean scores of the 177 respondents (58%) reflected the normal distribution of scores (mean 98, standard deviation [SD] 15.0) in the general population. Males had higher EI scores than females and Asian students demonstrated higher EI Total and branch scores than White students. The highest and lowest EI scores were obtained for the branches Understanding Emotions (mean 110, SD 19.0) and Perceiving Emotions (mean 94, SD 15.6), respectively. No significant correlations were found between EI Total or EI branch scores and any of the selection scores (UMAT, TER and Interview). Discussion This study offers information that can be used to compare the EI scores of medical students with those of other health professionals. No relationship was identified between cognition (measured by the UMAT) and skill (measured by the MSCEIT®) in the interpersonal domain and EI. Further studies are required to explore whether UMAT Section 2 is measuring EI, if there are associations between EI and academic performance and if EI can be used to predict the performance of junior doctors.

Doctors' perceptions of why 360-degree feedback does (not) work: a qualitative study.

Abstract: OBJECTIVES Delivery of 360-degree feedback is widely used in revalidation programmes. However, little has been done to systematically identify the variables that influence whether or not performance improvement is actually achieved after such assessments. This study aims to explore which factors represent incentives, or disincentives, for consultants to implement suggestions for improvement from 360-degree feedback. METHODS In 2007, 109 consultants in the Netherlands were assessed using 360-degree feedback and portfolio learning. We carried out a qualitative study using semi-structured interviews with 23 of these consultants, purposively sampled based on gender, hospital, work experience, specialty and views expressed in a previous questionnaire. A grounded theory approach was used to analyse the transcribed tape-recordings. RESULTS We identified four groups of factors that can influence consultants' practice improvement after 360-degree feedback: (i) contextual factors related to workload, lack of openness and social support, lack of commitment from hospital management, free-market principles and public distrust; (ii) factors related to feedback; (iii) characteristics of the assessment system, such as facilitators and a portfolio to encourage reflection, concrete improvement goals and annual follow-up interviews, and (iv) individual factors, such as self-efficacy and motivation. CONCLUSIONS It appears that 360-degree feedback can be a positive force for practice improvement provided certain conditions are met, such as that skilled facilitators are available to encourage reflection, concrete goals are set and follow-up interviews are carried out. This study underscores the fact that hospitals and consultant groups should be aware of the existing lack of openness and absence of constructive feedback. Consultants indicated that sharing personal reflections with colleagues could improve the quality of collegial relationships and heighten the chance of real performance improvement.

Smart strategies for doctors and doctors-in-training: heuristics in medicine

Abstract: CONTEXT How do doctors make sound decisions when confronted with probabilistic data, time pressures and a heavy workload? One theory that has been embraced by many researchers is based on optimisation, which emphasises the need to integrate all information in order to arrive at sound decisions. This notion makes heuristics, which use less than complete information, appear as second-best strategies. In this article, we challenge this pessimistic view of heuristics. METHODS We introduce two medical problems that involve decision making to the reader: one concerns coronary care issues and the other macrolide prescriptions. In both settings, decision-making tools grounded in the principles of optimisation and heuristics, respectively, have been developed to assist doctors in making decisions. We explain the structure of each of these tools and compare their performance in terms of their facilitation of correct predictions. RESULTS For decisions concerning both the coronary care unit and the prescribing of macrolides, we demonstrate that sacrificing information does not necessarily imply a forfeiting of predictive accuracy, but can sometimes even lead to better decisions. Subsequently, we discuss common misconceptions about heuristics and explain when and why ignoring parts of the available information can lead to the making of more robust predictions. CONCLUSIONS Heuristics are neither good nor bad per se, but, if applied in situations to which they have been adapted, can be helpful companions for doctors and doctors-in-training. This, however, requires that heuristics in medicine be openly discussed, criticised, refined and then taught to doctors-in-training rather than being simply dismissed as harmful or irrelevant. A more uniform use of explicit and accepted heuristics has the potential to reduce variations in diagnoses and to improve medical care for patients.

Design principles for virtual patients: a focus group study among students.

Abstract: Objectives This study aimed to examine what students perceive as the ideal features of virtual patient (VP) design in order to foster learning with a special focus on clinical reasoning. Methods A total of 104 Year 5 medical students worked through at least eight VPs representing four different designs during their paediatric clerkship. The VPs were presented in two modes and differed in terms of the authenticity of the user interface (with or without graphics support), predominant question type (long- versus short-menu questions) and freedom of navigation (relatively free versus predetermined). Each mode was presented in a rich and a poor version with regard to the use of different media and questions and explanations explicitly directed at clinical reasoning. Five groups of between four and nine randomly selected students (n = 27) participated in focus group interviews facilitated by a moderator using a questioning route. The interviews were videotaped, transcribed and analysed. Summary reports were approved by the students. Results Ten principles of VP design emerged from the analysis. A VP should be relevant, of an appropriate level of difficulty, highly interactive, offer specific feedback, make optimal use of media, help students focus on relevant learning points, offer recapitulation of key learning points, provide an authentic web-based interface and student tasks, and contain questions and explanations tailored to the clinical reasoning process. Conclusions Students perceived the design principles identified as being conducive to their learning. Many of these principles are supported by the results of other published studies. Future studies should address the effects of these principles using quantitative controlled designs.