Showing papers in "Medical Education in 2010"

A critical review of simulation-based medical education research: 2003-2009

Abstract: Objectives This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit. Methods This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969–2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003–2009. Results The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record. Conclusions Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts. Medical Education 2010: 44: 50–63

Cognitive load theory in health professional education: design principles and strategies

Abstract: CONTEXT Cognitive load theory aims to develop instructional design guidelines based on a model of human cognitive architecture. The architecture assumes a limited working memory and an unlimited long-term memory holding cognitive schemas; expertise exclusively comes from knowledge stored as schemas in long-term memory. Learning is described as the construction and automation of such schemas. Three types of cognitive load are distinguished: intrinsic load is a direct function of the complexity of the performed task and the expertise of the learner; extraneous load is a result of superfluous processes that do not directly contribute to learning, and germane load is caused by learning processes that deal with intrinsic cognitive load. OBJECTIVES This paper discusses design guidelines that will decrease extraneous load, manage intrinsic load and optimise germane load. DISCUSSION Fifteen design guidelines are discussed. Extraneous load can be reduced by the use of goal-free tasks, worked examples and completion tasks, by integrating different sources of information, using multiple modalities, and by reducing redundancy. Intrinsic load can be managed by simple-to-complex ordering of learning tasks and working from low- to high-fidelity environments. Germane load can be optimised by increasing variability over tasks, applying contextual interference, and evoking self-explanation. The guidelines are also related to the expertise reversal effect, indicating that design guidelines for novice learners are different from guidelines for more experienced learners. Thus, well-designed instruction for novice learners is different from instruction for more experienced learners. Applications in health professional education and current research lines are discussed.

Motor skill learning and performance: a review of influential factors.

Abstract: Objectives Findings from the contemporary psychological and movement science literature that appear to have implications for medical training are reviewed. Specifically, the review focuses on four factors that have been shown to enhance the learning of motor skills: observational practice; the learner’s focus of attention; feedback, and self-controlled practice. Observational Practice Observation of others, particularly when it is combined with physical practice, can make important contributions to learning. This includes dyad practice (i.e. practice in pairs), which is not only cost-effective, but can also enhance learning. Focus of Attention Studies examining the role of the performer’s focus of attention have consistently demonstrated that instructions inducing an external focus (directed at the movement effect) are more effective than those promoting an internal focus (directed at the performer’s body movements). An external focus facilitates automaticity in motor control and promotes movement efficiency. Feedback Feedback not only has an informational function, but also has motivational properties that have an important influence on learning. For example, feedback after successful trials and social-comparative (normative) feedback indicating better than average performance have been shown to have a beneficial effect on learning. Self-Controlled Practice Self-controlled practice, including feedback and model demonstrations controlled by the learner, has been found to be more effective than externally controlled practice conditions. Conclusions All factors reviewed in this article appear to have both informational and motivational influences on learning. The findings seem to reflect general learning principles and are assumed to have relatively broad applicability. Therefore, the consideration of these factors in designing procedures for medical training has the potential to enhance the effectiveness and efficiency of training. Medical Education 2010: 44: 75–84

State of the science in health professional education: effective feedback.

Abstract: BACKGROUND Effective feedback may be defined as feedback in which information about previous performance is used to promote positive and desirable development. This can be challenging as educators must acknowledge the psychosocial needs of the recipient while ensuring that feedback is both honest and accurate. Current feedback models remain reductionist in their approach. They are embedded in the hierarchical, diagnostic endeavours of the health professions. Even when it acknowledges the importance of two-way interactions, feedback often remains an educator-driven, one-way process. LESSONS FROM THE LITERATURE An understanding of the various types of feedback and an ability to actively seek an appropriate approach may support feedback effectiveness. Facilitative rather than directive feedback enhances learning for high achievers. High-achieving recipients undertaking complex tasks may benefit from delayed feedback. It is hypothesised that such learners are supported by reducing interruptions during the task. If we accept that medical students and doctors are high achievers, we can draw on some guiding principles from a complex and rarely conclusive literature. Feedback should focus on the task rather than the individual and should be specific. It should be directly linked to personal goals. Self-assessment as a means to identify personal learning requirements has no theoretical basis. Motivated recipients benefit from challenging facilitated feedback from external sources. A NEW MODEL To achieve truly effective feedback, the health professions must nurture recipient reflection-in-action. This builds on self-monitoring informed by external feedback. An integrated approach must be developed to support a feedback culture. Early training and experience such as peer feedback may over time support the required cultural change. Opportunities to provide feedback must not be missed, including those to impart potentially powerful feedback from high-stakes assessments. Feedback must be conceptualised as a supported sequential process rather than a series of unrelated events. Only this sustained approach will maximise any effect.

Identity, identification and medical education: why should we care?

Abstract: Context: Medical education is as much about the development of a professional identity as it is about knowledge learning. Professional identities are contested and accepted through the synergistic internal–external process of identification that is constituted in and through language and artefacts within specific institutional sites. The ways in which medical students develop their professional identity and subsequently conceptualise their multiple identities has important implications for their own well-being, as well as for the relationships they form with fellow workers and patients. Objectives: This paper aims to provide an overview of some current thinking about identity and identification with the aim of highlighting some of the core underlying processes that have relevance for medical educationists and researchers. These processes include aspects that occur within embodied individuals (e.g. the development of multiple identities and how these are conceptualised), processes specifically to do with interactional aspects of identity (e.g. how identities are constructed and co-constructed through talk) and institutional processes of identity (e.g. the influence of patterns of behaviour within specific hierarchical settings). Implications: Developing a systematic understanding into the processes through which medical students develop their identities will facilitate the development of educational strategies, placing medical students’ identification at the core of medical education. Conclusions: Understanding the process through which we develop our identities has profound implications for medical education and entails that we adopt and develop new methods of collecting and analysing data. Embracing this challenge will provide better insights into how we might develop students’ learning experiences, facilitating their development of a doctor identity that is more in line with desired policy requirements.

Applying the science of learning to medical education

Abstract: OBJECTIVE The goal of this paper is to examine how to apply the science of learning to medical education. SCIENCE OF LEARNING The science of learning is the scientific study of how people learn. Multimedia learning - learning from words and pictures - is particularly relevant to medical education. The cognitive theory of multimedia learning is an information-processing explanation of how people learn from words and pictures. It is based on the idea that people have separate channels for processing words and pictures, that the capacity to process information in working memory is limited, and that meaningful learning requires appropriate cognitive processing during learning. SCIENCE OF INSTRUCTION The science of instruction is the scientific study of how to help people learn. Three important instructional goals are: to reduce extraneous processing (cognitive processing that does not serve an instructional objective) during learning; to manage essential processing (cognitive processing aimed at representing the essential material in working memory) during learning, and to foster generative processing (cognitive processing aimed at making sense of the material) during learning. Nine evidence-based principles for accomplishing these goals are presented. CONCLUSIONS Applying the science of learning to medical education can be a fruitful venture that improves medical instruction and cognitive theory.

Research paradigms in medical education research

Abstract: CONTEXT The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence. METHODS This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research. DISCUSSION This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice. CONCLUSIONS This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.

Diagnostic error and clinical reasoning.

Abstract: CONTEXT There is a growing literature on diagnostic errors. The consensus of this literature is that most errors are cognitive and result from the application of one or more cognitive biases. Such biased reasoning is usually associated with 'System 1' (non-analytic, pattern recognition) thinking. METHODS We review this literature and bring in evidence from two other fields: research on clinical reasoning, and research in psychology on 'dual-process' models of thinking. We then synthesise the evidence from these fields exploring possible causes of error and potential solutions. RESULTS We identify that, in fact, there is very little evidence to associate diagnostic errors with System 1 (non-analytical) reasoning. By contrast, studies of dual processing show that experts are as likely to commit errors when they are attempting to be systematic and analytical. We then examine the effectiveness of various approaches to reducing errors. We point out that educational strategies aimed at explaining cognitive biases are unlikely to succeed because of limited transfer. Conversely, there is an accumulation of evidence that interventions directed at specifically encouraging both analytical and non-analytical reasoning have been shown to result in small, but consistent, improvements in accuracy. CONCLUSIONS Diagnostic errors are not simply a consequence of cognitive biases or over-reliance on one kind of thinking. They result from multiple causes and are associated with both analytical and non-analytical reasoning. Limited evidence suggests that strategies directed at encouraging both kinds of reasoning will lead to limited gains in accuracy.

The effectiveness of self-directed learning in health professions education: a systematic review.

Abstract: Medical Education 2010: 44: 1057–1068 Objectives Given the continuous advances in the biomedical sciences, health care professionals need to develop the skills necessary for life-long learning. Self-directed learning (SDL) is suggested as the methodology of choice in this context. The purpose of this systematic review is to determine the effectiveness of SDL in improving learning outcomes in health professionals. Methods We searched MEDLINE, EMBASE, ERIC and PsycINFO through to August 2009. Eligible studies were comparative and evaluated the effect of SDL interventions on learning outcomes in the domains of knowledge, skills and attitudes. Two reviewers working independently selected studies and extracted data. Standardised mean difference (SMD) and 95% confidence intervals (95% CIs) were estimated from each study and pooled using random-effects meta-analysis. Results The final analysis included 59 studies that enrolled 8011 learners. Twenty-five studies (42%) were randomised. The overall methodological quality of the studies was moderate. Compared with traditional teaching methods, SDL was associated with a moderate increase in the knowledge domain (SMD 0.45, 95% CI 0.23–0.67), a trivial and non-statistically significant increase in the skills domain (SMD 0.05, 95% CI − 0.05 to 0.22), and a non-significant increase in the attitudes domain (SMD 0.39, 95% CI − 0.03 to 0.81). Heterogeneity was significant in all analyses. When learners were involved in choosing learning resources, SDL was more effective. Advanced learners seemed to benefit more from SDL. Conclusions Moderate quality evidence suggests that SDL in health professions education is associated with moderate improvement in the knowledge domain compared with traditional teaching methods and may be as effective in the skills and attitudes domains.

Emotional intelligence in medicine: a systematic review through the context of the ACGME competencies.

Abstract: OBJECTIVES Emotional intelligence (EI) involves the perception, processing, regulation and management of emotions. This article aims to systematically review the evidence for EI in medicine through the context of the Accreditation Council for Graduate Medical Education (ACGME) competencies. METHODS MEDLINE, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials were searched for English-language articles published between January 1980 and March 2009. The grey literature was also searched and experts in the field contacted for additional studies. Two independent reviewers selected articles which reported empirical research studies about clinicians or medical students. Conceptual articles and opinion pieces and commentaries were excluded. Information about the measure used to assess EI, the study parameter or domain, and the educational or clinical outcome (with specific relation to the ACGME competencies) was extracted. RESULTS The literature search identified 485 citations. An abstract review led to the retrieval of 24 articles for full-text assessment, of which 16 articles were included in the final review. Eleven studies focused on postgraduates, four on undergraduates and one on medical school applicants. Six out of seven studies found women to have higher EI than men. Higher EI was reported to positively contribute to the doctor-patient relationship (three studies), increased empathy (five studies), teamwork and communication skills (six studies), and stress management, organisational commitment and leadership (three studies). CONCLUSIONS Measures of EI correlate with many of the competencies that modern medical curricula seek to deliver. Further research is required to determine whether training can improve EI and thus augment educational and clinical outcomes.

Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students.

Abstract: Medical Education 2010: 44: 1016–1026 Context Burnout is prevalent among medical students and is a predictor of subsequent serious consideration of dropping out of medical school and suicide ideation. Understanding of the factors that protect against burnout is needed to guide student wellness programmes. Methods A total of 1321 medical students attending five institutions were studied longitudinally (2006–2007). The surveys included standardised instruments to evaluate burnout, quality of life, fatigue and stress. Additional items explored social support, learning climate, life events, employment status and demographics. Students who did not have burnout at either time-point (resilient students) were compared with those who indicated burnout at one or both time-points (vulnerable students) using a Wilcoxon–Mann–Whitney test or Fisher’s exact test. Similarly, the differences between those who recovered and those who were chronically burned out were also compared in students with burnout at the first time-point. Logistic regression modelling was employed to evaluate associations between the independent variables and resiliency to and recovery from burnout. Results Overall, 792 (60.0%) students completed the burnout inventory at both time-points. No differences in demographic characteristics were observed between resilient (290/792 [36.6%]) and vulnerable (502/792 [63.4%]) students. Resilient students were less likely to experience depression, had a higher quality of life, were less likely to be employed, had experienced fewer stressful life events, reported higher levels of social support, perceived their learning climate more positively and experienced less stress and fatigue (all p < 0.05) than vulnerable students. On multivariable analysis, perceiving student education as a priority for faculty staff, experiencing less stress, not being employed and being a minority were factors independently associated with recovery from burnout. Conclusions Modifiable individual factors and learning climate characteristics including employment status, stress level and perceptions of the prioritising of student education by faculty members relate to medical students’ vulnerability to burnout.

Active patient involvement in the education of health professionals.

Abstract: Context: Patients as educators (teaching intimate physical examination) first appeared in the 1960s Since then, rationales for the active involvement of patients as educators have been well articulated There is great potential to promote the learning of patient-centred practice, interprofessional collaboration, community involvement, shared decision making and how to support self-care Methods: We reviewed and summarised the literature on active patient involvement in health professional education Results: A synthesis of the literature reveals increasing diversity in the ways in which patients are involved in education, but also the movement’s weaknesses Most initiatives are ‘one-off’ events and are reported as basic descriptions There is little rigorous research or theory of practice or investigation of behavioural outcomes The literature is scattered and uses terms (such as ‘patient’!) that are contentious and confusing Conclusions: We propose future directions for research and development, including a taxonomy to facilitate dialogue, an outline of a research strategy and reference to a comprehensive bibliography covering all health and human services

The transition from medical student to junior doctor: today’s experiences of Tomorrow’s Doctors

Abstract: CONTEXT Medical education in the UK has recently undergone radical reform. Tomorrow's Doctors has prescribed undergraduate curriculum change and the Foundation Programme has overhauled postgraduate education. OBJECTIVES This study explored the experiences of junior doctors during their first year of clinical practice. In particular, the study sought to gain an understanding of how junior doctors experienced the transition from the role of student to that of practising doctor and how well their medical school education had prepared them for this. METHODS The study used qualitative methods comprising of semi-structured interviews and audio diary recordings with newly qualified doctors based at the Peninsula Foundation School in the UK. Purposive sampling was used and 31 of 186 newly qualified doctors self-selected from five hospital sites. All 31 participants were interviewed once and 17 were interviewed twice during the year. Ten of the participants also kept audio diaries. Interview and audio diary data were transcribed verbatim and thematically analysed with the aid of a qualitative data analysis software package. RESULTS The findings show that, despite recent curriculum reforms, most participants still found the transition stressful. Dealing with their newly gained responsibility, managing uncertainty, working in multi-professional teams, experiencing the sudden death of patients and feeling unsupported were important themes. However, the stress of transition was reduced by the level of clinical experience gained in the undergraduate years. CONCLUSIONS Medical schools need to ensure that students are provided with early exposure to clinical environments which allow for continuing 'meaningful' contact with patients and increasing opportunities to 'act up' to the role of junior doctor, even as students. Patient safety guidelines present a major challenge to achieving this, although with adequate supervision the two aims are not mutually exclusive. Further support and supervision should be made available to junior doctors in situations where they are dealing with the death of a patient and on surgical placements.

It’s NOT rocket science: rethinking our metaphors for research in health professions education

Abstract: Context The health professional education community is struggling with a number of issues regarding the place and value of research in the field, including: the role of theory-building versus applied research; the relative value of generalisable versus contextually rich, localised solutions, and the relative value of local versus multi-institutional research. In part, these debates are limited by the fact that the health professional education community has become deeply entrenched in the notion of the physical sciences as presenting a model for ‘ideal’ research. The resulting emphasis on an ‘imperative of proof’ in our dominant research approaches has translated poorly to the domain of education, with a resulting denigration of the domain as ‘soft’ and ‘unscientific’ and a devaluing of knowledge acquired to date. Similarly, our adoption of the physical sciences’‘imperative of generalisable simplicity’ has created difficulties for our ability to represent well the complexity of the social interactions that shape education and learning at a local level. Methods Using references to the scientific paradigms associated with the physical sciences, this paper will reconsider the place of our current goals for education research in the production and evolution of knowledge within our community, and will explore the implications for enhancing the value of research in health professional education. Conclusions Reorienting education research from its alignment with the imperative of proof to one with an imperative of understanding, and from the imperative of simplicity to an imperative of representing complexity well may enable a shift in research focus away from a problematic search for proofs of simple generalisable solutions to our collective problems, towards the generation of rich understandings of the complex environments in which our collective problems are uniquely embedded. Medical Education 2010: 44: 31–39

Second-year medical students' motivational beliefs, emotions, and achievement.

Abstract: Medical Education 2010: 44: 1203–1212 Context A challenge for medical educators is to better understand the personal factors that lead to individual success in medical school and beyond. Recently, educational researchers in fields outside medicine have acknowledged the importance of motivation and emotion in students’ learning and performance. These affective factors have received less emphasis in the medical education literature. Objectives This longitudinal study examined the relations between medical students’ motivational beliefs (task value and self-efficacy), achievement emotions (enjoyment, anxiety and boredom) and academic achievement. Methods Second-year medical students (n = 136) completed motivational beliefs and achievement emotions surveys following their first and second trimesters, respectively. Academic achievement was operationalised as students’ average course examination grades and national board shelf examination scores. Results The results largely confirmed the hypothesised relations between beliefs, emotions and achievement. Structural equation modelling revealed that task value beliefs were positively associated with course-related enjoyment (standardised regression coefficient [β] = 0.59) and were negatively related to boredom (β = − 0.25), whereas self-efficacy beliefs were negatively associated with course-related anxiety only (β = − 0.47). Furthermore, student enjoyment was positively associated with national board shelf examination score (β = 0.31), whereas anxiety and boredom were both negatively related to course examination grade (β = − 0.36 and − 0.27, respectively). The overall structural model accounted for considerable variance in each of the achievement outcomes: R2 = 0.20 and 0.14 for the course examination grade and national board shelf examination score, respectively. Conclusions This study suggests that medical students’ motivational beliefs and achievement emotions are important contributors to their academic achievement. These results have implications for medical educators striving to understand the personal factors that influence learning and performance in medical training.

Concept maps in medical education: an analytical literature review

Abstract: OBJECTIVES As the medical profession continues to change, so do the educational methods by which medical students are taught. Various authors have acknowledged the need for alternative teaching and learning strategies that will enable medical students to retain vast amounts of information, integrate critical thinking skills and solve a range of complex clinical problems. Previous research has indicated that concept maps may be one such teaching and learning strategy. This article aims to: (i) review the current research on concept maps as a potential pedagogical approach to medical student learning, and (ii) discuss implications for medical student teaching and learning, as well as directions for future research. METHODS The literature included in this review was obtained by searching library databases including ACADEMIC SEARCH, ERIC, EBSCOHost, PsychINFO, PsychARTICLES, PubMed/MEDLINE, CINAHL and EMBASE. This literature review is a summary of both conceptual and empirically published literature on the uses of concept mapping in medical education. RESULTS The 35 studies reviewed here indicate that concept maps function in four main ways: (i) by promoting meaningful learning; (ii) by providing an additional resource for learning; (iii) by enabling instructors to provide feedback to students, and (iv) by conducting assessment of learning and performance. CONCLUSIONS This review provides ideas for medical school faculty staff on the use of concept maps in teaching and learning. Strategies such as fostering critical thinking and clinical reasoning, incorporating concept mapping within problem-based learning, and using concept mapping in group and collaborative learning are identified. New developments in medical education include the use of serial concept maps, concept maps as a methodology to assist learners with lower cognitive competence, and the combination of group concept maps with structured feedback.

Privacy, professionalism and Facebook: a dilemma for young doctors.

Abstract: OBJECTIVES This study aimed to examine the nature and extent of use of the social networking service Facebook by young medical graduates, and their utilisation of privacy options. METHODS We carried out a cross-sectional survey of the use of Facebook by recent medical graduates, accessing material potentially available to a wider public. Data were then categorised and analysed. Survey subjects were 338 doctors who had graduated from the University of Otago in 2006 and 2007 and were registered with the Medical Council of New Zealand. Main outcome measures were Facebook membership, utilisation of privacy options, and the nature and extent of the material revealed. RESULTS A total of 220 (65%) graduates had Facebook accounts; 138 (63%) of these had activated their privacy options, restricting their information to 'Friends'. Of the remaining 82 accounts that were more publicly available, 30 (37%) revealed users' sexual orientation, 13 (16%) revealed their religious views, 35 (43%) indicated their relationship status, 38 (46%) showed photographs of the users drinking alcohol, eight (10%) showed images of the users intoxicated and 37 (45%) showed photographs of the users engaged in healthy behaviours. A total of 54 (66%) members had used their accounts within the last week, indicating active use. CONCLUSIONS Young doctors are active members of Facebook. A quarter of the doctors in our survey sample did not use the privacy options, rendering the information they revealed readily available to a wider public. This information, although it included some healthy behaviours, also revealed personal information that might cause distress to patients or alter the professional boundary between patient and practitioner, as well as information that could bring the profession into disrepute (e.g. belonging to groups like 'Perverts united'). Educators and regulators need to consider how best to advise students and doctors on societal changes in the concepts of what is public and what is private.

What do we mean by web‐based learning? A systematic review of the variability of interventions

Abstract: OBJECTIVES Educators often speak of web-based learning (WBL) as a single entity or a cluster of similar activities with homogeneous effects. Yet a recent systematic review demonstrated large heterogeneity among results from individual studies. Our purpose is to describe the variation in configurations, instructional methods and presentation formats in WBL. METHODS We systematically searched MEDLINE, EMBASE, ERIC, CINAHL and other databases (last search November 2008) for studies comparing a WBL intervention with no intervention or another educational activity. From eligible studies we abstracted information on course participants, topic, configuration and instructional methods. We summarised this information and then purposively selected and described several WBL interventions that illustrate specific technologies and design features. RESULTS We identified 266 eligible studies. Nearly all courses (89%) used written text and most (55%) used multimedia. A total of 32% used online communication via e-mail, threaded discussion, chat or videoconferencing, and 9% implemented synchronous components. Overall, 24% blended web-based and non-computer-based instruction. Most web-based courses (77%) employed specific instructional methods, other than text alone, to enhance the learning process. The most common instructional methods (each used in nearly 50% of courses) were patient cases, self-assessment questions and feedback. We describe several studies to illustrate the range of instructional designs. CONCLUSIONS Educators and researchers cannot treat WBL as a single entity. Many different configurations and instructional methods are available for WBL instructors. Researchers should study when to use specific WBL designs and how to use them effectively.

A primer on classical test theory and item response theory for assessments in medical education

Abstract: Context A test score is a number which purportedly reflects a candidate’s proficiency in some clearly defined knowledge or skill domain. A test theory model is necessary to help us better understand the relationship that exists between the observed (or actual) score on an examination and the underlying proficiency in the domain, which is generally unobserved. Common test theory models include classical test theory (CTT) and item response theory (IRT). The widespread use of IRT models over the past several decades attests to their importance in the development and analysis of assessments in medical education. Item response theory models are used for a host of purposes, including item analysis, test form assembly and equating. Although helpful in many circumstances, IRT models make fairly strong assumptions and are mathematically much more complex than CTT models. Consequently, there are instances in which it might be more appropriate to use CTT, especially when common assumptions of IRT cannot be readily met, or in more local settings, such as those that may characterise many medical school examinations. Objectives The objective of this paper is to provide an overview of both CTT and IRT to the practitioner involved in the development and scoring of medical education assessments. Methods The tenets of CCT and IRT are initially described. Then, main uses of both models in test development and psychometric activities are illustrated via several practical examples. Finally, general recommendations pertaining to the use of each model in practice are outlined. Discussion Classical test theory and IRT are widely used to address measurement-related issues that arise from commonly used assessments in medical education, including multiple-choice examinations, objective structured clinical examinations, ward ratings and workplace evaluations. The present paper provides an introduction to these models and how they can be applied to answer common assessment questions. Medical Education 2010: 44: 109–117

Health-related quality of life of medical students

Abstract: OBJECTIVES: Mental problems such as stress, anxiety and depression have been described among medical students and are associated with poor academic and professional performance. It has been speculated that these problems impair students' quality of life (QoL). The authors aimed to assess the health-related QoL (HRQL) of medical students throughout their 6 years of training at a school with a traditional curriculum. METHODS: Of a total of 490 students attending our institution's medical school, 38 were surveyed in February 2006 (incoming Year 1 group, surveyed when students were in the second week of Year 1 classes) and 352 were surveyed in February 2007 (students in Years 1-6). Students self-reported their HRQL and depressive symptoms using the Short-Form Health Survey (SF-36) and the Beck Depression Inventory (BDI). Comparisons were performed according to year in training, presence of depressive symptoms, gender, living arrangements and correlations with family income. RESULTS: The students' ages ranged from 18 to 31 years (median 22.3 years). Students in Years 2, 3, 4 and 6 had lower scores for mental and physical dimensions of HRQL compared with the incoming Year 1 group (P < 0.01), with the largest difference observed for Year 3 students. Students with depressive symptoms had lower scores in all domains of the SF-36 (P < 0.01). Female students had lower HRQL scores than males (P < 0.01). No differences were observed for students living with versus without family and no correlation with family income was found. CONCLUSIONS: Major impairments in HRQL were observed among Year 3 students, students with depressive symptoms and women. Medical schools should institute efforts to ensure that students' HRQL and emotional support are maintained, particularly during critical phases of medical training.

Burnout and engagement among resident doctors in the Netherlands: A national study

Abstract: Objectives This study was performed in order to gather insight into the well-being of Dutch medical residents. Methods In 2005, all Dutch residents registered through the Medical Registration Committee (n = 5245) were sent a self-report questionnaire to assess socio-demographic and work-related characteristics, burnout and engagement. Results Of the 5140 eligible residents, 2115 completed the questionnaire (41%). Of those, 21% fulfilled the criteria for moderate to severe burnout and 27% were highly engaged with their work. Women reported more emotional exhaustion and less depersonalisation than men; age was weakly but significantly related to depersonalisation, and married residents and parents reported less depersonalisation than their single or childless counterparts. More men than women were found to be highly engaged and men specifically reported more vigour. Number of years in training was weakly but significantly related to absorption. With regard to occupational risk factors, significant between-group differences were found for the effects of clinical setting on emotional exhaustion, engagement, vigour and absorption. Residents in training in a mental health clinic were most emotionally exhausted and those in a rehabilitation centre were least engaged. General surgery represented the specialty with the lowest number of residents suffering from burnout, followed by obstetrics and gynaecology and any supportive specialty. General surgery residents were also found to be more highly engaged, vigorous, dedicated and absorbed than others. Conclusions As more than a fifth of the medical residents who responded could be diagnosed as suffering from burnout, we conclude that this problem needs addressing in the Dutch health care system, especially given that a relationship was proven between burnout and suboptimal patient care. We must look for solutions and interventions which will improve the work situation of medical residents. Striving for healthy workers in health care has to become daily practice.

Adding emotional stressors to training in simulated cardiopulmonary arrest enhances participant performance.

Abstract: Medical Education 2010: 44: 1006–1015 Objectives Advanced cardiac life support (ACLS) skills tend to degrade over time. There is mounting evidence that high-fidelity simulation (HFS) is advantageous to teaching ACLS. The aspects of HFS that enhance learning are not entirely clear, but the anxiety generated by a scenario may enhance retention through well-established learning pathways. We sought to determine whether an HFS with added emotional stress could provoke anxiety and, if so, whether or not participants learning ACLS would demonstrate better written and applied knowledge retention 6 months after their initial course. Methods Twenty-five student volunteers from Year 1 and 2 at Mount Sinai School of Medicine were randomly assigned to a control group or an emotional content (EC) group for a sudden cardiac death management course. All subjects were monitored for heart rate and were assessed using the State-Trait Anxiety Inventory. Control group participants experienced an HFS in which actors were not scripted to add stress, whereas EC group participants were exposed to an emotionally charged environment using the same actors. Results Participants across the two groups were well matched by resting heart rates, baseline anxiety and prior ACLS knowledge. The EC group participants experienced greater anxiety than controls (mean state anxiety score: 35.0 versus 28.2 [p < 0.05]; average heart rate [HR]: 94.6 bpm versus 72.9 bpm [p < 0.05]; maximum HR: 120.8 bpm versus 95.3 bpm [p < 0.05]). Six months later, written test scores were similar, but the EC group participants achieved higher practical competency examination (‘mega code’) scores than controls (32.5 versus 25.0; p < 0.05). Independent t-tests and Spearman rank coefficients were employed where applicable. Conclusions Simulation with added emotional stressors led to greater anxiety during ACLS instruction but correlated with enhanced performance of ACLS skills after this course. The quantitative and qualitative values of added stressors need further exploration, but these values represent important variables in simulation-based education.

Career choices of medical students: a national survey of 1780 students.

Abstract: OBJECTIVES Many factors influence the career specialty decisions made by medical students. The aim of this study was to broaden consideration of the determinants of specialty choice in a large population of medical students in their sixth year of study. METHODS A total of 2588 students distributed across all of the 39 medical schools in France participated in a National Practice Examination in December 2008, after which an electronic questionnaire was administered. Study criteria were: population characteristics; demographics, and motivation for and drawbacks to medical specialty choice. RESULTS A total of 1780 students (1111 women, 62%) responded to the questionnaire (69% response rate). The mean age of respondents was 23.8 years (22-35 years). Of these, 1555 students (87%) stated their preferred medical specialty. Surgical and medical specialties were the two specialties selected most frequently by students (n = 729, 47%). General practice was chosen by 20%. Gender influenced the choice of specialty: 88% of future paediatricians, 82% of gynaecologists and 77% of general practitioners (GPs) were women (p < 0.05). Main motivating factors included interesting diseases, opportunities for private practice and patient contact. Main drawbacks limiting the choice of other specialties were poor quality of life, an exclusively hospital-based career and loss of patient contact. Gender was the criterion most associated with significant differences in factors of motivation for or discouragement from a career. Patient contact and opportunities for private practice were significantly highlighted by future GPs compared with students opting for the medical or surgical specialties (p < 0.0001). CONCLUSIONS Students' career choices regarding specialties or general practice result from the interplay among several factors. Career interest in general practice is particularly low. Initiatives to address the factors affecting student career choices regarding less favoured specialties and to deal with the growing feminisation of the profession, which will lead to irreversible changes in clinical practice, are required.

Peer teaching: a randomised controlled trial using student‐teachers to teach musculoskeletal ultrasound

Abstract: Medical Education 2010:44:148–155 Objectives This study (a post-intervention assessment) was designed to assess the effectiveness of peer-assisted learning (PAL) using student-teachers (STs) with limited training to teach complicated technical skills for interpreting ultrasound images of the shoulder. Methods Students in Years 3 and 4 of medical school were randomly assigned to two groups. In the PAL group (PG), teaching was delivered by a group of nine STs from Years 3 and 4, who undertook a 30-minute general training and 1 week of self-teaching. In the staff-led group (SG), students were taught by a group of three ultrasound-experienced doctors. Exposure took place in two separate lessons (each of 120 minutes) and introduced eight standard sectional planes (EULAR) using a 10-MHz Nemio™ XG system (Toshiba Medical Systems GmbH). The theoretical and practical learning outcomes were tested using a multiple-choice question (MCQ) test and an objective structured clinical examination (OSCE). Qualitative differences were evaluated using Likert scale-based items. Results Evaluation of differences between the PG (n = 75) and SG (n = 76) in the theoretical (MCQ score; P = 0.644) and practical (total OSCE score; P = 0.133) outcomes showed no difference between the two groups. However, the STs themselves showed significantly better results overall (P < 0.05). Staff members were rated more highly than STs, especially on items relating to competence (P < 0.05). Conclusions Complicated technical skills can be adequately taught to students using the PAL system by STs with limited training. Self-teaching learning strategies are successful in contexts of limited teacher training. However, despite positive objective results, STs still face prejudice from students with regard to competency.

Differences in motives between Millennial and Generation X medical students.

Abstract: OBJECTIVES Three domains comprise the field of human assessment: ability, motive and personality. Differences in personality and cognitive abilities between generations have been documented, but differences in motive between generations have not been explored. This study explored generational differences in medical students regarding motives using the Thematic Apperception Test (TAT). METHODS Four hundred and twenty six students (97% response rate) at one medical school (Generation X = 229, Millennials = 197) who matriculated in 1995 & 1996 (Generation X) or in 2003 & 2004 (Millennials) wrote a story after being shown two TAT picture cards. Student stories for each TAT card were scored for different aspects of motives: Achievement, Affiliation, and Power. RESULTS A multiple analysis of variance (p < 0.05) showed significant differences between Millennials' and Generation X-ers' needs for Power on both TAT cards and needs for Achievement and Affiliation on one TAT card. The main effect for gender was significant for both TAT cards regarding Achievement. No main effect for ethnicity was noted. CONCLUSIONS Differences in needs for Achievement, Affiliation and Power exist between Millennial and Generation X medical students. Generation X-ers scored higher on the motive of Power, whereas Millennials scored higher on the motives of Achievement and Affiliation.

Threat and challenge: cognitive appraisal and stress responses in simulated trauma resuscitations.

Abstract: OBJECTIVES Training and practice in medicine are inherently stressful. Research into the effects of acute stressors has revealed significant variability in individual responses to stressors, with performance impairments occurring in those who demonstrate elevated subjective and physiological responses. Cognitive appraisals (subjective assessment of situational demands and available resources) of a stressor have been proposed as a predictor variable in stress responses. However, the relationship between cognitive appraisal and stress responses has not been tested empirically in complex realistic situations. The purpose of this study was to determine the extent to which cognitive appraisal affects a medical trainee's subjective and physiological stress responses to high-acuity simulated clinical situations. METHODS Thirteen emergency medicine and general surgery residents participated in high (HS) and low (LS) stress trauma resuscitation simulations. Subjective (cognitive appraisal and State-Trait Anxiety Inventory [STAI]) and physiological (salivary cortisol) measures were collected at baseline and in response to participation in each scenario. RESULTS Post-scenario STAI scores, cognitive appraisal and cortisol levels were higher in the HS scenario compared with the LS scenario. For the participants who appraised the scenarios as 'threats' (in which the demands outweighed the resources), the ratio of perceived demands to resources was positively correlated with cortisol levels (r = 0.59, p < 0.05) and STAI responses (r = 0.64, p < 0.05). By contrast, for the participants who appraised the scenarios as 'challenges' (in which resources were sufficient to meet the demands), the perceived ratio of demands to resources was not correlated with either the STAI scores or cortisol levels. CONCLUSIONS Subjective appraisals of a situation appear to play an important role in stress responses, which have previously been shown to impair performance. As such, training for high-acuity events should include interventions targeting stress management skills.

Self-organisation, integration and curriculum in the complex world of medical education

Abstract: CONTEXT The world of medical education is more complex than ever and there seems to be no end in sight. Complexity science is particularly relevant as medical education embraces a movement towards more authentic curricula focusing on integration, interactive small-group learning, and early and sustained clinical and community experiences. DISCUSSION A medical school as a whole, and the expression of its curriculum through the interactions, exchanges and learning that take place within and outside of it, is a complex system. Complexity science, a derivative of the natural sciences, is the study of the dynamics, conditions and consequences of interactions. It addresses the nature of the conditions favourable to change and transformation (learning). CONCLUSIONS The core process of complexity, self-organisation, requires a system that is open and far from equilibrium, with ill-defined boundaries and a large number of non-linear interactions involving short-loop feedback. In such a system, knowledge does not exist objectively 'out there'; rather, it exists as a result of the exchange between participants, an action that becomes knowing. Understanding is placed between participants rather than being contained in one or the other. Knowledge is not constructed separately in the mind of the knower, but, rather, it emerges; it is co-created during the exchange in an authentic recursive transactive process. Learning and knowing become adaptive responses to continuously evolving circumstances. An approach to curriculum based on self-organisation is characterised as rich, recursive, relational and rigorous and it illuminates how a curriculum can be understood as a complex adaptive system. The perspective of complexity applied to medical education broadens and enriches research questions relevant to health professions education. It focuses our attention onto how we are together as human beings. How we respond to and frame the issues of learning and understanding that challenge contemporary medicine and, by extension, medical education, in a complex and rapidly changing world can have profound effects on the preparedness of tomorrow's health professionals and their impact on society.

Help, I'm losing patient-centredness! Experiences of medical students and their teachers

Abstract: Medical Education 2010: 44: 662–673 Objectives Despite all educational efforts, the literature shows an ongoing decline in patient-centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient-centredness in order to gain a better understanding of the factors that determine its development. Methods We conducted 11 focus groups on the subject of learning and teaching about patient-centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the ‘sensitising concepts’ provided by the Attitude–Social Influence–Self-Efficacy (ASE) model. Results Although students express positive attitudes towards patient-centredness and acquire patient-centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today’s challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient-centred skills. However, when students lack self-efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non-patient-centred role models and are overwhelmed by powerful experiences, they lose their patient-centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self-awareness and self-care are important qualities of the central phenomenon of the ‘doctor-as-person’, which is identified as a missing concept in the ASE model. The student–supervisor relationship is found to be key to learning patient-centredness and has several functions: it facilitates the direct transmission of patient-centred skills, knowledge and attitudes; it provides social support of students’ patient-centred behaviour; it provides support of the ‘student-as-person’; it mirrors patient-centredness by being student-centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student-centred education and guidance be offered, self-awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. Conclusions Supportive student–doctor relationships, student-centred education and guidance that addresses the needs of the doctor-as-person are central to the development of patient-centredness. Medical education requires patient-centred, self-caring and self-aware role models.

Feedback, the various tasks of the doctor, and the feedforward alternative

Abstract: Medical Education 2010: 44: 1166–1174 Objectives This study aims to alert users of feedback to its dangers, explain some of its complexities and offer the feedforward alternative. Methods We review the damage that feedback may cause to both motivation and performance. We provide an initial solution to the puzzle of the feedback sign (positive versus negative) using the concepts of promotion focus and prevention focus. We discuss additional open questions pertaining to feedback sign and consider implications for health care systems. Results Feedback that threatens the self is likely to debilitate recipients and, on average, positive and negative feedback are similar in their effects on performance. Positive feedback contributes to motivation and performance under promotion focus, but the same is true for negative feedback under prevention focus. We offer an alternative to feedback – the feedforward interview – and describe a brief protocol and suggestions on how it might be used in medical education. Conclusions Feedback is a double-edged sword; its effective application includes careful consideration of regulatory focus and of threats to the self. Feedforward may be a good substitute for feedback in many settings.

'You're judged all the time!' Students' views on professionalism: a multicentre study

Abstract: OBJECTIVES This study describes how medical students perceive professionalism and the context in which it is relevant to them. An understanding of how Phase 1 students perceive professionalism will help us to teach this subject more effectively. Phase 1 medical students are those in the first 2 years of a 5-year medical degree. METHODS Seventy-two undergraduate students from two UK medical schools participated in 13 semi-structured focus groups. Focus groups, carried out until thematic saturation occurred, were recorded and transcribed verbatim. Data were analysed and coded using NVivo 8, using a grounded theory approach with constant comparison. RESULTS From the analysis, seven themes regarding professionalism emerged: the context of professionalism; role-modelling; scrutiny of behaviour; professional identity; 'switching on' professionalism; leniency (for students with regard to professional standards), and sacrifice (of freedom as an individual). Students regarded professionalism as being relevant in three contexts: the clinical, the university and the virtual. Students called for leniency during their undergraduate course, opposing the guidance from Good Medical Practice. Unique findings were the impact of clothing and the online social networking site Facebook on professional behaviour and identity. Changing clothing was described as a mechanism by which students 'switch on' their professional identity. Students perceived society to be struggling with the distinction between doctors as individuals and professionals. This extended to the students' online identities on Facebook. Institutions' expectations of high standards of professionalism were associated with a feeling of sacrifice by students caused by the perception of constantly 'being watched'; this perception was coupled with resentment of this intrusion. Students described the significant impact that role-modelling had on their professional attitudes. CONCLUSIONS This research offers valuable insight into how Phase 1 medical students construct their personal and professional identities in both the offline and online environments. Acknowledging these learning mechanisms will enhance the development of a genuinely student-focused professionalism curriculum.