Early practical experience and the social responsiveness of clinical education: systematic review

Playback Theatre as a tool to enhance communication in medical education

Playback Theatre (PT) is an improvisational form of theatre in which a group of actors "play back" real life stories told by audience members. In PT, a conductor elicits moments, feelings and stories from audience members, and conducts mini-interviews with those who volunteer a moment of their lives to be re-enacted or "played" for the audience. A musician plays music according to the theme of each story, and 4-5 actors listen to the interview and perform the story that has just been told. PT has been used in a large number of settings as a tool to share stories in an artistic manner. Despite its similarities to psychodrama, PT does not claim to be a form of therapy. We offered two PT performances to first year medical students at Baylor College of Medicine in Houston, Texas, to bring the students a safe and fun environment, conducive to sharing feelings and moments related to being a medical student. Through the moments and stories shared by students, we conclude that there is an enormous need in this population for opportunities to communicate the many emotions associated with medical school and with healthcare-related personal experiences, such as anxiety, pride, or anger. PT proved a powerful tool to help students communicate.

The integration of cancer survivorship training in the curriculum of hematology/oncology fellows and radiation oncology residents

BACKGROUND

Cancer specialists require an understanding of survivors' needs to insure optimal delivery of care. Training programs currently focus on treatment, while survivorship care focuses on time after treatment. Cancer survivorship training represents an education paradigm shift.

METHODS

The Cancer Survivorship Workshop was held at the James P. Wilmot Cancer Center of the University of Rochester in academic year 2011-2012, with six sessions held. Objectives included the following: learning about survivorship from patient, primary care physician, and oncologist perspectives using a curriculum based on survivorship literature; designing treatment summaries (TSs) and survivorship care plans (SCPs) for five malignancies (lung, breast, prostate, colon, and lymphoma); and establishing collaboration between hematology/oncology (HO) and radiation oncology (RO) trainees by working together in teams. Course impact was assessed pre- and post-training using a 13-question survey. Questions were answered using a 10-point scale, with predefined rating for each question.

RESULTS

Statistically significant differences in responses to several survey questions were observed comparing pre- and post-course experience. Improvement was noted in comfort discussing survivorship issues with patients (p = 0.001), reported knowledge of survivorship care for five types of cancer (p = 0.002), confidence in ability to explain a SCP (p = 0.001), and comfort discussing late effects of cancer treatment (p = 0.001). Five unique sets of TS and SCPs were completed.

CONCLUSIONS

This study demonstrates the feasibility of implementing cancer survivorship education into the curriculum of HO and RO training.

IMPLICATIONS FOR CANCER SURVIVORS

The project was designed with intension to optimize survivor care through enhanced provider training.

Authentic early experience in Medical Education: a socio-cultural analysis identifying important variables in learning interactions within workplaces

This paper addresses the question 'what are the variables influencing social interactions and learning during Authentic Early Experience (AEE)?' AEE is a complex educational intervention for new medical students. Following critique of the existing literature, multiple qualitative methods were used to create a study framework conceptually orientated to a socio-cultural perspective. Study participants were recruited from three groups at one UK medical school: students, workplace supervisors, and medical school faculty. A series of intersecting spectra identified in the data describe dyadic variables that make explicit the parameters within which social interactions are conducted in this setting. Four of the spectra describe social processes related to being in workplaces and developing the ability to manage interactions during authentic early experiences. These are: (1) legitimacy expressed through invited participation or exclusion; (2) finding a role-a spectrum from student identity to doctor mindset; (3) personal perspectives and discomfort in transition from lay to medical; and, (4) taking responsibility for 'risk'-moving from aversion to management through graded progression of responsibility. Four further spectra describe educational consequences of social interactions. These spectra identify how the reality of learning is shaped through social interactions and are (1) generic-specific objectives, (2) parallel-integrated-learning, (3) context specific-transferable learning and (4) performing or simulating-reality. Attention to these variables is important if educators are to maximise constructive learning from AEE. Application of each of the spectra could assist workplace supervisors to maximise the positive learning potential of specific workplaces.

Students' experience of prison health education during medical school

BACKGROUND

Social responsibility and accountability can be important core values in medical education. At the University of British Columbia, undergraduate medical students engage in prison health community service-learning opportunities in regional correctional facilities.

METHODS

To describe the impact of prison health exposure on pre-clinical medical students, in-depth individual interviews were conducted with individuals who had participated in a prison health medical education program. All interviews were transcribed verbatim, and interpretive descriptive methods were used to inductively derive thematic findings to describe students' experiences.

RESULTS

Major themes emerged as students reported how (1) exposure to incarcerated populations increases students' insight into issues that diverse marginalized sub-populations encounter; (2) positive interactions with the incarcerated individuals enhances relationship building; (3) collaboration reinforces teamwork skills and (4) community placements garner important learning opportunities within the medical school curriculum.

CONCLUSIONS

Our findings demonstrated that pre-clinical exposure to incarcerated individuals and prison health education provided a unique setting for medical students to develop an increased sense of social responsibility and accountability.

A mentorship-based preclinical elective increases exposure, confidence, and interest in surgery

BACKGROUND

The predicted shortage of surgeons is of growing concern with declining medical student interest in surgical careers. We hypothesized that earlier exposure to operative experiences and the establishment of resident mentors through a preclinical elective would enhance student confidence and interest in surgery.

METHODS

We developed a preclinical elective in surgery, which served as an organized curriculum for junior medical students to experience surgery through a paired resident-mentorship model. We assessed student exposure and confidence with clinical activities before and after the elective (N = 24, 100% response rate). We compared these students with a cohort of peers not enrolled in the elective (N = 147, 67% response rate).

RESULTS

We found significantly improved confidence (2.8 vs 4.4) and clinical exposure (2.4 vs 4.3) before versus after the elective, with precourse scores equal to matched peers.

CONCLUSIONS

This elective incorporates elements that have been shown to positively influence student decision making in surgical career choice. The mentorship model promotes residents as educators, whereas the elective provides a means for early identification of students interested in surgery.

'Soft and fluffy': medical students' attitudes towards psychology in medical education

Psychology is viewed by medical students in a negative light. In order to understand this phenomenon, we interviewed 19 medical students about their experiences of psychology in medical education. Interviews were transcribed verbatim and analysed using thematic analysis. Four main themes were generated: attitudes, teaching culture, curriculum factors and future career path; negative attitudes were transmitted by teachers to students and psychology was associated with students opting for a career in general practice. In summary, appreciation of psychology in medical education will only happen if all educators involved in medical education value and respect each other's speciality and expertise.

An integrative review and evidence-based conceptual model of the essential components of pre-service education

BACKGROUND

With decreasing global resources, a pervasive critical shortage of skilled health workers, and a growing disease burden in many countries, the need to maximize the effectiveness and efficiency of pre-service education in low-and middle-income countries has never been greater.

METHODS

We performed an integrative review of the literature to analyse factors contributing to quality pre-service education and created a conceptual model that shows the links between essential elements of quality pre-service education and desired outcomes.

RESULTS

The literature contains a rich discussion of factors that contribute to quality pre-service education, including the following: (1) targeted recruitment of qualified students from rural and low-resource settings appears to be a particularly effective strategy for retaining students in vulnerable communities after graduation; (2) evidence supports a competency-based curriculum, but there is no clear evidence supporting specific curricular models such as problem-based learning; (3) the health workforce must be well prepared to address national health priorities; (4) the role of the preceptor and preceptors' skills in clinical teaching, identifying student learning needs, assessing student learning, and prioritizing and time management are particularly important; (5) modern, Internet-enabled medical libraries, skills and simulation laboratories, and computer laboratories to support computer-aided instruction are elements of infrastructure meriting strong consideration; and (6) all students must receive sufficient clinical practice opportunities in high-quality clinical learning environments in order to graduate with the competencies required for effective practice. Few studies make a link between PSE and impact on the health system. Nevertheless, it is logical that the production of a trained and competent staff through high-quality pre-service education and continuing professional development activities is the foundation required to achieve the desired health outcomes. Professional regulation, deployment practices, workplace environment upon graduation and other service delivery contextual factors were analysed as influencing factors that affect educational outcomes and health impact.

CONCLUSIONS

Our model for pre-service education reflects the investments that must be made by countries into programmes capable of leading to graduates who are competent for the health occupations and professions at the time of their entry into the workforce.

Learning through work: clinical shadowing of junior doctors by first year medical students

BACKGROUND

Early clinical contact (ECC) is a key feature of undergraduate programmes, yet they make significant demands on senior clinicians delivering it and usually focus on patient contact.

AIMS

To explore the potential of an ECC activity oriented to work as a junior doctor and the clinical environment, and the use of very junior doctors as facilitators of this learning.

METHODS

For two academic years, all first year medical students at UCL Medical School shadowed a Foundation Year (FY) doctor for a four-hour shift to experience and understand the work of junior doctors. Feedback from students and FY doctors was gathered and analysed.

RESULTS

The students found the FY doctors to be good near-peer tutors and enjoyed exploring the clinical environment, but felt that the unstructured learning environment was difficult. The FY doctors felt that learning in and about the clinical environment was an important learning outcome for the students, although they found supervising junior medical students in a shadowing context difficult.

CONCLUSIONS

FY doctors are an effective and under-utilised resource in introducing novices to the role of a medical professional in the clinical environment; however students and FY doctors need support to maximise the learning potential of early shadowing activities.

Can medical education rise to the challenge of the African crisis?

In the face of the worsening health crisis in Africa, educationalists there and beyond are challenged to identify their role in resolving the crisis. The training of doctors has to be re-orientated so that they are well equipped to lead the way towards improving the health situation and effectively participating in improving the general condition of the people. This can be achieved by medical schools having control of their duties and functions and using these powers to train doctors who are community-orientated, able to identify clinical and epidemiological problems and find suitable solutions. Doctors of the future should be comfortable working in the community with other members of health teams and confident in addressing all health-related matters in the community. During their formative years in medical school they should acquire the skills to continue self-education. This paper discusses some of the important steps that should be taken by medical schools, taking into account the present situation in Africa.

Minding the gap between communication skills simulation and authentic experience

CONTEXT

Concurrent exposure to simulated and authentic experiences during undergraduate medical education is increasing. The impact of gaps or differences between contemporaneous experiences has not been adequately considered. We address two questions. How do new undergraduate medical students understand contemporaneous interactions with simulated and authentic patients? How and why do student perceptions of differences between simulated and authentic patient interactions shape their learning?

METHODS

We conducted an interpretative thematic secondary analysis of research data comprising individual interviews (n = 23), focus groups (three groups, n = 16), and discussion groups (four groups, n = 26) with participants drawn from two different year cohorts of Year 1 medical students. These methods generated data from 48 different participants, of whom 17 provided longitudinal data. In addition, data from routinely collected written evaluations of three whole Year 1 cohorts (response rates ≥ 88%, n = 378) were incorporated into our secondary analysis dataset. The primary studies and our secondary analysis were conducted in a single UK medical school with an integrated curriculum.

RESULTS

Our analysis identified that students generate knowledge and meaning from their simulated and authentic experiences relative to each other and that the resultant learning differs in quality according to meaning created by comparing and contrasting contemporaneous experiences. Three themes were identified that clarify how and why the contrasting of differences is an important process for learning outcomes. These are preparedness, responsibility for safety, and perceptions of a gap between theory and practice.

CONCLUSIONS

We propose a conceptual framework generated by reframing common metaphors that refer to the concept of the gap to develop educational strategies that might maximise useful learning from perceived differences. Educators need to 'mind' gaps in collaboration with students if synergistic learning is to be constructed from contemporaneous exposure to simulated and authentic patient interactions. The strategies need to be tested in practice by teachers and learners for utility. Further research is needed to understand gaps in other contexts.

The consequences of authentic early experience for medical students: creation of mētis

CONTEXT

Authentic early experience (AEE) describes experiences provided to new medical students to undertake 'human contact' to enhance learning. Although the concept of AEE is not new, and was commonplace prior to the Flexner Report of 1910, little is known about how or why meaning and knowledge are constructed through early student placements in medical, social and voluntary workplaces. Variance among settings means AEE is a collection of non-uniform, complex educational interventions which require students to make repeated transitions between different workplaces and their university institution. The purpose of this paper is to develop theory in this context.

METHODS

We report on a study undertaken in a UK medical school using interviews and discussion groups to generate data from students, workplace supervisors and school faculty staff. We used narrative analysis to access knowledge and meaning construction, in combination with analytic tools drawn from thematic and interpretative approaches to phenomena. We sought to refine theoretical understanding through the application of mētis, a socio-cultural theory novel to the field of medical education.

RESULTS

Scott's concept of mētis provides a useful theoretical framework for understanding how AEE works for students in terms of their creation of meaning and how they choose to use it in relation to formally recognised knowledge. Knowledge and meaning, generated as a consequence of AEE, contained dichotomies and paradoxes. Students improvised, in the face of unpredictability and uncertainty, to create a form of mētis that allowed them to handle the perceived competing demands of AEE settings and the medical school.

DISCUSSION

We demonstrate how meaning making can be conceived of as student mētis arising from social processes in students' learning interactions. We suggest that the development of collaborative working with students could potentiate positive forms of student mētis, thereby maximising desirable educational consequences. Further work is required to establish effective ways to do this.

Development and evaluation of a community immersion program during preclinical medical studies: a 15-year experience at the University of Geneva Medical School

BACKGROUND

Significant changes in medical education have occurred in recent decades because of new challenges in the health sector and new learning theories and practices. This might have contributed to the decision of medical schools throughout the world to adopt community-based learning activities. The community-based learning approach has been promoted and supported by the World Health Organization and has emerged as an efficient learning strategy. The aim of the present paper is to describe the characteristics of a community immersion clerkship for third-year undergraduate medical students, its evolution over 15 years, and an evaluation of its outcomes.

METHODS

A review of the literature and consensus meetings with a multidisciplinary group of health professionals were used to define learning objectives and an educational approach when developing the program. Evaluation of the program addressed students' perception, achievement of learning objectives, interactions between students and the community, and educational innovations over the years.

RESULTS

The program and the main learning objectives were defined by consensus meetings among teaching staff and community health workers, which strengthened the community immersion clerkship. Satisfaction, as monitored by a self-administered questionnaire in successive cohorts of students, showed a mean of 4.4 on a five-point scale. Students also mentioned community immersion clerkship as a unique community experience. The learning objectives were reached by a vast majority of students. Behavior evaluation was not assessed per se, but specific testimonies show that students have been marked by their community experience. The evaluation also assessed outcomes such as educational innovations (eg, students teaching other students), new developments in the curriculum (eg, partnership with the University of Applied Health Sciences), and interaction between students and the community (eg, student development of a website for a community health institution).

CONCLUSION

The community immersion clerkship trains future doctors to respond to the health problems of individuals in their complexity, and strengthens their ability to work with the community.

Acquisition of clinical competence: Added value of clerkship real-life contextual experience

BACKGROUND

Medical students' limited access to patients induces a shift of learning activities from clinical wards to classrooms.

AIM

Identify clinical competencies specifically acquired during real-life contextual clerkship added to case-based tutorials, by a prospective, controlled study.

METHODS

Students entering our eight-week internal medicine (IM) clerkship attended paper case-based tutorials about 10 common presenting complaints and were assigned to an IM specialty ward. For each tutorial case, two groups of students were created: those assigned to a ward, the specialty of which was unrelated to the case (case-unrelated ward, CUW) and those assigned to a ward, the specialty of which was related to the case (case-related ward, CRW).

RESULTS

Forty-one students (30 CUW and 11 CRW) volunteered for the study. Both groups had similar previous experiences and pre-clerkship exam scores. The CRW students collected more relevant clinical information from the patient (69% vs. 55% of expected items, p=0.001) and elaborated charts of better quality (47% vs. 39% of expected items, p=0.05). Clinical-knowledge mean score was similar (70%) in both groups (p=0.92).

CONCLUSIONS

While paper-case tutorials did provide students with clinical knowledge, real contextual experience brought additional, specific competencies. This supports the preservation of clinical exposure with supervision and feedback.

An evaluation of University of Cape Town medical students’ community placements in South Africa

Background

Fourth-year medical students at the University of Cape Town (UCT) work closely with stakeholders in community teaching sites to conduct community-based research projects and follow-up health promotion interventions during their Public Health training.

Objectives

This study evaluated the placements as a learning experience from the perspectives of past students and community stakeholders.

Methods

A total of 32 projects were randomly selected out of 232 projects undertaken during 2006, 2008 and 2009. Two students and a stakeholder involved with each project were sampled. A standardised survey was emailed to students and in-depth interviews were held with stakeholders.

Results

Fifty two per cent of 64 students and 57% of 25 stakeholders responded. Most students felt that the placements enhanced their academic experience and confidence in research skills, and were an effective form of learning. Perceived challenges included time constraints and, for a minority, inadequately prepared settings and stakeholders. Stakeholders felt that the placements empowered the communities and prepared students for the realities of working as a medical professional. They viewed students as a valuable resource and believed that student projects addressed important community myths and health problems. Recommendations from students and stakeholders included more time for the Public Health block, follow-up interventions for greater continuity, and better alignment of projects with stakeholder programmes.

Conclusion

The evaluation reveals both the importance and challenges of community placements and identifies areas of improvement. Despite the limited duration of the placements, they offered valuable community-based learning experiences for the students and worthwhile benefits for the communities.

Sharing methodology: a worked example of theoretical integration with qualitative data to clarify practical understanding of learning and generate new theoretical development

BACKGROUND

Theoretical integration is a necessary element of study design if clarification of experiential learning is to be achieved. There are few published examples demonstrating how this can be achieved.

AIMS

This methodological article provides a worked example of research methodology that achieved clarification of authentic early experiences (AEEs) through a bi-directional approach to theory and data.

METHODS

Bi-directional refers to our simultaneous use of theory to guide and interrogate empirical data and the use of empirical data to refine theory. We explain the five steps of our methodological approach: (1) understanding the context; (2) critique on existing applications of socio-cultural models to inform study design; (3) data generation; (4) analysis and interpretation and (5) theoretical development through a novel application of Metis.

RESULTS

These steps resulted in understanding of how and why different outcomes arose from students participating in AEE. Our approach offers a mechanism for clarification without which evidence-based effective ways to maximise constructive learning cannot be developed. In our example it also contributed to greater theoretical understanding of the influence of social interactions.

CONCLUSION

By sharing this example of research undertaken to develop both theory and educational practice we hope to assist others seeking to conduct similar research.

Impact of increased authenticity in instructional format on preclerkship students' performance: a two-year, prospective, randomized study

PURPOSE

To address whether increasingly authentic instructional formats are more effective in improving preclerkship medical students' performance.

METHOD

From 2007 to 2009, the authors conducted a prospective, randomized, crossover study with second-year medical students in a clinical reasoning course at the Uniformed Services University of the Health Sciences. The authors randomly assigned students to one of three cohorts and used instructional formats of differing authenticity (paper, DVD, standardized patient) to teach three subject areas (abdominal pain, anemia, polyuria). Each cohort received one instructional format for each subject area. The authors collected outcome measures (objective structured clinical exam, video quiz, and essay exam scores) at the end of each academic year. They stratified the students into tertiles by first-year grade point average to investigate the impact of instructional formats on learners of different abilities.

RESULTS

Outcomes for students in the top tertile improved with increased authenticity of the instructional format compared with outcomes for students in the middle and bottom tertiles (0.188 versus -0.038 and -0.201, P=.001 and .027, respectively). However, outcomes for students in the bottom tertile decreased when students were given only the paper case, compared with the middle and top tertiles (-0.374 versus 0.043 and 0.023, respectively, P=.001), but subsequently improved with more authentic instructional formats.

CONCLUSIONS

The authors could not demonstrate that increased authenticity of the instructional format resulted in improved learner performance. However, they believe that there may be some benefit to tailoring preclerkship clinical education based on students' ability.

Learning physical examination skills outside timetabled training sessions: what happens and why?

Lack of published studies on students' practice behaviour of physical examination skills outside timetabled training sessions inspired this study into what activities medical students undertake to improve their skills and factors influencing this. Six focus groups of a total of 52 students from Years 1-3 using a pre-established interview guide. Interviews were recorded, transcribed and analyzed using qualitative methods. The interview guide was based on questionnaire results; overall response rate for Years 1-3 was 90% (n = 875). Students report a variety of activities to improve their physical examination skills. On average, students devote 20% of self-study time to skill training with Year 1 students practising significantly more than Year 3 students. Practice patterns shift from just-in-time learning to a longitudinal selfdirected approach. Factors influencing this change are assessment methods and simulated/real patients. Learning resources used include textbooks, examination guidelines, scientific articles, the Internet, videos/DVDs and scoring forms from previous OSCEs. Practising skills on fellow students happens at university rooms or at home. Also family and friends were mentioned to help. Simulated/real patients stimulated students to practise of physical examination skills, initially causing confusion and anxiety about skill performance but leading to increased feelings of competence. Difficult or enjoyable skills stimulate students to practise. The strategies students adopt to master physical examination skills outside timetabled training sessions are self-directed. OSCE assessment does have influence, but learning takes place also when there is no upcoming assessment. Simulated and real patients provide strong incentives to work on skills. Early patient contacts make students feel more prepared for clinical practice.

Design, implementation and evaluation of a community health training program in an integrated problem-based medical curriculum: a fifteen-year experience at the University of Geneva Faculty of Medicine

BACKGROUND

In the literature the need for relevance in medical education and training has been stressed. In the last 40 years medical schools have been challenged to train doctors competent to respond to community health needs. In the mid-90s the University of Geneva Faculty of Medicine introduced an integrated medical curriculum. In this initiative a particular emphasis was put in introducing a 6-year longitudinal and multidisciplinary Community Health Program (CHP).

OBJECTIVES

The aims of the present article are to describe the conception, elaboration and implementation of the CHP as well as its evolution over 15 years and the evaluation of its outcomes.

METHODS

The CHP was at its origin elaborated by a small group of highly motivated teachers and later on developed by a multi-disciplinary group of primary care physicians, epidemiologists, public health and bio-ethics specialists, occupational health professionals, lawyers and historians. Evaluation of the program outcomes included educational innovations, new developments of the curriculum and interactions between students and the community.

RESULTS

The CHP learning objectives and teaching modalities were defined by the multi-disciplinary group in consensus meetings which triggered a collaborative spirit among teachers and facilitated further developments. The evaluation procedures allowed the monitoring of students' satisfaction which remained high over the years, students' active participation which decreased over time and success at certifying exams which was globally as good as in basic life sciences. The evaluation also assessed outcomes such as educational innovations, new developments of the curriculum and interactions between students and the community.

CONCLUSION

As suggested in the literature, our experience shows that the students' direct exposure and practice in the community health environment is an effective training approach to broaden students' education by offering them a community perspective of health and disease.

Formal public health education and career outcomes of medical school graduates

BACKGROUND

Few data are available evaluating the associations of formal public health education with long-term career choice and professional outcomes among medical school graduates. The objective of this study was to determine if formal public health education via completion of a masters of public health (MPH) degree among US medical school graduates was associated with early and long-term career choice, professional satisfaction, or research productivity.

METHODS

We conducted a retrospective cohort study in 1108 physicians (17.1% completed a MPH degree) who had 10-20 years of follow-up post medical school graduation. Multivariable logistic regression analyses were conducted.

RESULTS

Compared to their counterparts with no MPH, medical school graduates with a MPH were more likely to have completed a generalist primary care residency only [relative risk (RR) 1.79, 95% confidence interval (CI) 1.35-2.29], obtain employment in an academic institution (RR 1.81; 95% CI 1.33-2.37) or government agency (RR 3.26; 95% CI 1.89-5.38), and practice public health (RR 39.84; 95% CI 12.13-107.38) or primary care (RR 1.59; 95% CI 1.18-2.05). Furthermore, medical school graduates with a MPH were more likely to conduct public health research (RR 8.79; 95% CI: 5.20-13.82), receive NIH or other federal funding (RR 3.11, 95% CI 1.74-5.33), have four or more peer-reviewed publications (RR 2.07; 95% CI 1.56-2.60), and have five or more scientific presentations (RR 2.31, 95% CI 1.70-2.98).

CONCLUSION

Formal public health education via a MPH was associated with career choice and professional outcomes among physicians.

Complementary and alternative medicine education for medical profession: systematic review

Purpose. To help integrate traditional, complementary and alternative medicine (TCAM) into health systems, efforts are being made to educate biomedical doctors (BMD) and medical students on TCAM. We systematically evaluated the effect of TCAM education on BMD and medical students' attitude, knowledge, and behavior towards TCAM utilization and integration with biomedical medicine. Methods. Evaluative studies were identified from four databases. Methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI). Study outcomes were classified using Kirkpatrick's hierarchy. Results. 3122 studies were identified and 12 studies of mediocre quality met inclusion criteria. Qualitative synthesis showed usage of diverse approaches including didactic, experiential learning, varying length, teacher background and intensity of exposure. More positive attitudes and improved knowledge after intervention were noted especially when teachers were BM trained. However, few studies assessed behavior change objectively. Finally, longer-term objective outcomes such as impact on patient care were not assessed. Conclusions. Lack of use of objective and reliable instruments preclude firm conclusion on the effect of TCAM education on study participants. However, positive changes, although mostly subjectively reported, were noted in most studies. Future evaluation should use validated or objective outcome assessments, and the value of using dual trained instructors.

Experiential learning: AMEE Guide No. 63

This Guide provides an overview of educational theory relevant to learning from experience. It considers experience gained in clinical workplaces from early medical student days through qualification to continuing professional development. Three key assumptions underpin the Guide: learning is 'situated'; it can be viewed either as an individual or a collective process; and the learning relevant to this Guide is triggered by authentic practice-based experiences. We first provide an overview of the guiding principles of experiential learning and significant historical contributions to its development as a theoretical perspective. We then discuss socio-cultural perspectives on experiential learning, highlighting their key tenets and drawing together common threads between theories. The second part of the Guide provides examples of learning from experience in practice to show how theoretical stances apply to clinical workplaces. Early experience, student clerkships and residency training are discussed in turn. We end with a summary of the current state of understanding.

Hidden benefits of a peer-mentored 'Hospital Orientation Day': first-year medical students' perspectives

BACKGROUND

Entering the clinical environment is potentially stressful for junior medical students.

AIMS

We evaluated first-year medical student feedback on a peer-mentored 'Hospital Orientation Day' designed to provide insight into future clinical training.

METHOD

Using a mixed methodology approach data were collected from first-year medical students. Responses to a questionnaire were used to develop a topic guide for focus groups held the next academic year. The questionnaire was completed by 230 first-year students and 32 second years participated in the interviews. Thematic analysis was used to draw conclusions.

RESULTS

Analysis of questionnaire responses indicated that students gained insight into future learning. Focus groups then generated five themes: (1) entering the hospital without fear, (2) linking the present with the future, (3) understanding the culture of learning in the clinical years, (4) a 'Backstage Pass' to the clinical world and (5) peer mentors make or break the day.

CONCLUSIONS

Using peer mentors during the Hospital Orientation Day allowed insight into future learning. We highlight the importance of student Mentors in the success of hospital orientation. To maximise the benefits for first years, we recommend a mentor selection procedure, mentor training opportunities and incentives to optimise mentor performance.

What do medical trainees think is so difficult about communicating with patients?

OBJECTIVE

To identify the communication skills medical trainees perceive themselves to avoid or use during initial clinical encounters and the areas of communication learning need they identify.

METHODS

446 2nd year undergraduate medical students were invited to take part in the study. Details of four encounters with patients were entered into a web-based electronic logbook by the student. Details included perception of use, success and requests for further training from a list of communication process skills.

RESULTS

395 (89%) students took part. Factor analysis yielded three types of skills: those used to manage the flow of interaction; the emotional content of the interaction; and structuring the interaction. Skills perceived as being used least often and least successfully and identified by the students as requiring further training were primarily those that involved managing the emotional aspects of interactions with patients rather than managing the flow of information.

CONCLUSION

Communication training should focus further on the emotional aspects of patient interactions in order to support students during early clinical encounters.

PRACTICE IMPLICATIONS

Skills required to manage emotional encounters need to be made more explicit to students. Opportunities to obtain feedback and develop competency should be offered as part of the core curriculum.

Method and reporting quality in health professions education research: a systematic review

CONTEXT

Studies evaluating reporting quality in health professions education (HPE) research have demonstrated deficiencies, but none have used comprehensive reporting standards. Additionally, the relationship between study methods and effect size (ES) in HPE research is unknown.

OBJECTIVES

This review aimed to evaluate, in a sample of experimental studies of Internet-based instruction, the quality of reporting, the relationship between reporting and methodological quality, and associations between ES and study methods.

METHODS

We conducted a systematic search of databases including MEDLINE, Scopus, CINAHL, EMBASE and ERIC, for articles published during 1990-2008. Studies (in any language) quantifying the effect of Internet-based instruction in HPE compared with no intervention or other instruction were included. Working independently and in duplicate, we coded reporting quality using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, and coded study methods using a modified Newcastle-Ottawa Scale (m-NOS), the Medical Education Research Study Quality Instrument (MERSQI), and the Best Evidence in Medical Education (BEME) global scale.

RESULTS

For reporting quality, articles scored a mean±standard deviation (SD) of 51±25% of STROBE elements for the Introduction, 58±20% for the Methods, 50±18% for the Results and 41±26% for the Discussion sections. We found positive associations (all p<0.0001) between reporting quality and MERSQI (ρ=0.64), m-NOS (ρ=0.57) and BEME (ρ=0.58) scores. We explored associations between study methods and knowledge ES by subtracting each study's ES from the pooled ES for studies using that method and comparing these differences between subgroups. Effect sizes in single-group pretest/post-test studies differed from the pooled estimate more than ESs in two-group studies (p=0.013). No difference was found between other study methods (yes/no: representative sample, comparison group from same community, randomised, allocation concealed, participants blinded, assessor blinded, objective assessment, high follow-up).

CONCLUSIONS

Information is missing from all sections of reports of HPE experiments. Single-group pre-/post-test studies may overestimate ES compared with two-group designs. Other methodological variations did not bias study results in this sample.

Real patient learning integrated in a preclinical block musculoskeletal disorders. Does it make a difference?

Although musculoskeletal disorders are the most common reason for general practitioner visits, training did not keep pace. Implementation of learning from patients with rheumatologic disorders linked together with the teaching of theoretical knowledge in the preclinical medical education might be an important step forward in the improvement of quality of care for these patients. The Leiden Medical School curriculum has implemented two non-obligatory real patient learning (RPL) practicals integrated within the preclinical block musculoskeletal disorders. This study investigates the educational effectiveness of the practicals, the expectations students have of RPL, and students’ satisfaction. Participants’ grades on the end-of-block test served as the test results of the educational effectiveness of the practicals and were compared with those of the non-participants. Qualitative data was collected by means of questionnaires generated by focus groups. The participants in practicals scored significantly higher at the end-of-block test. The expected effects of the contact with real patients concerned positive effects on cognition and skills. ‘Contextualizing of the theory’, ‘better memorizing of clinical pictures’, and ‘understanding of the impact of the disease’ were the most frequently mentioned effects of the practicals. Overall, the participants were (very) enthusiastic about this educational format. The RPL practicals integrated within a preclinical block musculoskeletal disorders are a valuable addition to the Leiden medical curriculum. This relatively limited intervention exhibits a strong effect on students’ performance in tests. Future research should be directed towards the long-term effects of this intervention.

Introduction of real patients into problem-based learning in preclinical first-year anatomy curriculum

BACKGROUND

Early patient contacts are considered important in medical education.

AIMS

We studied the influence of a real patient trigger on study motivation and learning in problem-based study groups of first-year medical and dentistry students.

METHODS

156 eligible students were allocated into 17 groups. Six randomly selected groups received both the real patient and paper trigger, and 11 groups received only the paper trigger. The immediate and later effects of the trigger were assessed with qualitative and quantitative questionnaires and exam scores. The tutors answered questionnaires concerning learning outcomes.

RESULTS

The students reported that the real patient trigger significantly improved their study motivation, understanding of the learning objectives and confidence in future patient encounters. The real patient trigger was considered significantly more interesting than the paper case. No statistically significant difference was observed in the exam scores. The tutors observed that groups with poor previous performance gained better results in study sessions.

CONCLUSIONS

Real patient triggers motivate students to learn basic medical sciences. Ways to present real patients to students should be considered in medical curricula from early on.

Opportunity or threat: the ambiguity of the consequences of transitions in medical education

OBJECTIVES

The alleged medical education continuum is interrupted by a number of major transitions. After starting medical school, the first transition students encounter is that from non-clinical to clinical training. The second transition is that of graduated student to junior doctor or specialist trainee, and the third concerns the specialist trainee's transition to medical specialist. As a first step towards a better understanding of the effects of transitions, this paper provides a critical overview of how these transitions have been conceptualised in the medical education domain. The findings are complemented with perspectives from the fields of transitional psychology and organisational socialisation. The transition into medical school is not reviewed.

METHODS

Using the term 'transition', six leading medical education journals were searched for relevant articles. A snowballing technique on the reference lists of the 44 relevant articles yielded 29 additional publications. Studies were reviewed and categorised as representing objectifying, clarifying, or descriptive and/or justifying research.

RESULTS

When students enter clinical training, they need to relearn what they thought they knew and they must learn new things in a more self-directed way. As junior doctors or specialist trainees, their main challenges involve handling the many responsibilities that accompany the delivery of patient care while simultaneously learning from the process of providing that care. As medical specialists, new non-medical tasks and decisions on how to delegate responsibilities become issues.

CONCLUSIONS

Research on transitions has objectified the challenges students and doctors face. Clarifying studies often lack conceptual frameworks that could help us to gain deeper insight into the observed phenomena. Psychology offers valuable theoretical perspectives that are applicable to medical education transitions. To transform a transition from a threat to a learning opportunity, medical education should assist students and doctors in developing the coping skills they need to effectively deal with the challenges presented by new environments.

Students' views on the impact of peer physical examination and palpation as a pedagogic tool for teaching and learning living human anatomy

BACKGROUND

Modern medical education teaching and learning approaches now lay emphasis on students acquiring knowledge, skills and attitudes relevant to medical practice.

AIMS

To explore students' perceived impacts of using hands-on approaches involving peer/life model physical examination and palpation in teaching and learning living human anatomy on their practice of physical examination of real patients.

METHODS

This study used exploratory focus groups and a questionnaire survey of years 3-5 medical students.

RESULTS

The focus group discussions revealed new insights into the positive impacts of the hands-on approaches on students' clinical skills and professional attitudes when dealing with patients. Students' exposure to the hands-on approaches helped them to feel comfortable with therapeutically touching unclothed patients' bodies and physically examining them in the clinical environment. At least 60% of the questionnaire survey respondents agreed with the focus group participants on this view. Over 75% also agreed that the hands-on experiences helped them develop good professional attitudes in their encounter with patients.

CONCLUSIONS

This study highlights the perceived educational value of the hands-on approaches as a pedagogic tool with a positive impact on students' clinical skills and professional attitudes that helps in easing their transition into clinical practice.

Institutional marginalisation and student resistance: barriers to learning about culture, race and ethnicity

Although education about culture, race and ethnicity has increasingly been viewed as an important addition to the medical undergraduate curriculum, internationally the evidence of its effectiveness is mixed. Research to date fails to show why. We chose to explore how contrasting approaches to learning about cultural diversity impacted on medical students. The views of second year students towards teaching about cultural diversity at two UK medical schools, with differently structured curricula, were explored using a series of focus groups (7). The findings, using a methodology based on a combination of grounded theory and thematic analysis identified two potentially competing views espoused by the students at both sites. First, they claimed that although cultural diversity was important, their medical schools marginalised and failed to adequately support effective teaching. Second, in contrast, they claimed that the medical school was an 'inappropriate' setting for successful teaching about cultural diversity. Students did not consider the subject matter to be of central relevance to biomedicine. They felt it should be learnt experientially in the workplace and socially among peers. These narratives represent two potentially conflicting standpoints, which might be understood through the sociological concept of 'habitus', where students conform to the institution's dominant values in order to succeed. The tensions identified in this study cannot be ignored if effective learning about race, ethnicity and culture is to be achieved. Early introduction to understanding the delivery of health care to diverse populations is needed. This should be accompanied by more open collaborative debate between tutors and students on the issues raised.

Medical students' professional identity development in an early nursing attachment

OBJECTIVES

The importance of early clinical experience for medical training is well documented. However, to our knowledge there are no studies that assess the influence of very early nursing attachments on the professional development and identity construction of medical students. Working as an assistant nurse while training to be a doctor may offer valuable learning experiences, but may also present the student with difficulties with respect to identity and identification issues. The aim of the present study was to describe first-year medical students' perceptions of nurses, doctors and their own future roles as doctors before and after a nursing attachment.

METHODS

A questionnaire containing open questions concerning students' perceptions of nurses, doctors and their own future roles as doctors was administered to all Year 1 medical students (n=347) before and directly after a 4-week nursing attachment in hospitals and nursing homes. We carried out two confirmatory focus group interviews. We analysed the data using qualitative and quantitative content analyses.

RESULTS

The questionnaire was completed by 316 students (response rate 91%). Before starting the attachment students regarded nurses as empathic, communicative and responsible. After the attachment students reported nurses had more competencies and responsibilities than they had expected. Students' views of doctors were ambivalent. Before and after the attachment, doctors were seen as interested and reliable, but also as arrogant, detached and insensible. However, students maintained positive views of their own future roles as doctors. Students' perceptions were influenced by age, gender and place of attachment.

CONCLUSIONS

An early nursing attachment engenders more respect for the nursing profession. The ambivalent view of doctors needs to be explored further in relation to students' professional development. It would seem relevant to attune supervision to the age and gender differences revealed in this study.

Fulfilling the mission of academic medicine: training residents in the health needs of prisoners

The single mission of academic medicine is the pursuit of health for all. This mandate serves as a reminder to focus care on vulnerable and underserved populations. The 12 million Americans who cycle through correctional facilities each year are arguably among the most vulnerable populations in this country; predominantly black, with a high burden of disease and many barriers to care after release. Medical training programs should provide exposure to the health needs of prisoners. Residents could establish care with inmates prior to release and arrange follow-up in the community. This addition to training would not only provide care to this underserved group, but also would train residents in the myriad problems prisoners face, and foster social responsibility.

What has changed in the evidence for early experience? Update of a BEME systematic review

BACKGROUND

We previously reviewed evidence published from 1992 to 2001 concerning early experience for healthcare undergraduates (Dornan T, Littlewood S, Margolis S, Scherpbier A, Spencer J, Ypinazar V. 2006. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. Med Teach 28:3-18). This subsequent study reviews evidence published from 2002 to 2008.

AIMS

Identify changes in the evidence base; determine the value of re-reviewing; set a future research agenda.

METHODS

The same search strategy as in the original review was repeated. Newly identified publications were critically appraised against the same benchmarks of strength and educational importance.

RESULTS

Twenty-four new empirical studies of early authentic experience in education of health professionals met our inclusion criteria, yielding 96 outcomes. Sixty five outcomes (from 22 studies) were both educationally important and based on strong evidence. A new significant theme was found: the use of early experience to help students understand and align themselves with patient and community perspectives on illness and healthcare. More publications were now from outside Europe and North America.

CONCLUSIONS

In addition to supporting the findings of our original review, this update shows an expansion in research sources, and a shift in research content focus. There are still questions, however, about how early authentic experience leads to particular learning outcomes and what will make it most educationally effective.

Students' hopes and fears about early patient contact: lessons to be learned about preparing and supporting students during the first year

BACKGROUND

Medical students increasingly have contact with real patients ('early patient contact', EPC) from the beginning of their first year. Little is known about their expectations of meeting patients at this time. Understanding their hopes and fears might usefully influence the design and delivery of EPC.

AIM

To explore students' views of EPC before arrival at medical school and the impact of EPC on them after 1 year.

METHODS

A two-part study comprising a pre-registration questionnaire, with open-ended questions, sent to the complete year group, and four focus groups conducted after 1 year with randomly selected students.

RESULTS

Students anticipated benefits from EPC, especially in promoting personal and professional development. After 1 year most of their hopes were realized. They feared feeling inadequate and doing harm to patients or themselves. Fears were reinforced when students felt underprepared, were not made welcome on hospital wards and treated disrespectfully by some staff.

CONCLUSION

Understanding how students anticipate meeting patients for the first time is crucial to maximize the educational potential of EPC. Students' preparation for EPC and the organization of these real patient encounters are of paramount importance in determining to what extent their hopes and fears are realized and their consequent learning.

Instructiveness of real patients and simulated patients in undergraduate medical education: a randomized experiment

PURPOSE

Few studies have compared the instructiveness of real patient contacts with simulated patient (SP) contacts. Although most of these studies found no difference, students often comment that the instructiveness of both encounters is dissimilar. The aims of this study were to evaluate which contact (real patient or SP) is perceived as most instructive by students and which variables contribute to this.

METHOD

The authors performed an experiment involving 163 first-year medical students, randomized to having a real patient contact (n = 61) or SP contact (n = 102). Quantitative (questionnaires) and qualitative (focus groups) methods were used to evaluate the perceived instructiveness of the contact.

RESULTS

The general instructiveness of both real patient contacts and SP contacts was marked high. Several differences between the evaluations of real patient contacts and SP contacts were found. For example, students considered real patient contacts less helpful in practicing communication skills and considered the real patients' feedback less relevant. The focus group interviews yielded explanations for many of the differences found. Students regarded real patients as more authentic. However, SPs were better informed about the purpose of the consultation and provided the student with more specific feedback.

CONCLUSIONS

Students consider authenticity an important advantage of real patients. Their difficult recruitment is an important disadvantage, however, SPs have important advantages compared with real patients--for example, their feedback. The choice of real patient contacts or SP contacts for medical education depends on factors like the phase of the curriculum and the aim of the encounter.

The use of standardized patients to teach medical students clinical skills in ambulatory care settings

BACKGROUND

Ambulatory medicine is being increasingly emphasized in undergraduate medical education. Because of the limited availability of real patients, we introduced a standardized patient (SP) encounter program in an ambulatory care setting.

AIMS

This study was undertaken to assess the usefulness of SPs for teaching undergraduate students clinical skills in ambulatory settings.

METHOD

Third-year medical students met two different SPs, who presented common authentic problems, during internal medicine clerkship. Each SP encounter of 30 min was followed by SP and a tutor's feedback, using a video recording of the SP encounter. We surveyed students for program evaluation purposes at the end of their three-year internal medicine clerkships (from 2006 to 2008).

RESULTS

Most students found that the consecutive SP sessions were instructive and helpful. Video recordings of clinical encounters allowed students to reflect on their behavior and receive feedback from tutors. However, students identified several weaknesses of these SP encounters. For example, pre-exposure to the SP scenario reduced tension of the experience and inconsistent feedback from tutors caused confusion.

CONCLUSIONS

SP encounters in an ambulatory care setting, followed by tutor's feedback based on a video recording, can be used for teaching basic clinical ambulatory care skills.

Public health education for medical students: rising to the professional challenge

Public health competencies, especially as they relate to the management of chronic disease, will be of increasing importance to the global health-care workforce. The General Medical Council's recommendations on basic medical education have helped to entrench the position of public health and related disciplines. Tomorrow's Doctors has recently been updated. This article describes the indicative goals that should underpin the development of undergraduate medical education in public health, presented in a national statement. The statement was originally produced on behalf of academic departments of public health and related disciplines in UK medical schools. The dearth of evidence in this field leaves many questions for future educational research.

Exposure of medical students to pharmaceutical marketing in primary care settings: frequent and influential

It is known that interaction between pharmaceutical companies and medical professionals may lead to corruption of professional values, irrational use of medicine, and negative effects on the patient-physician relationship. Medical students frequently interact with pharmaceutical company representatives and increasingly accept their gifts. Considering the move toward early clinical encounters and community-based education, which expose students early to pharmaceutical representatives, the influence of those gifts is becoming a matter of concern. This study examines the frequency and influence of student exposure to drug marketing in primary care settings, as well as student perceptions of physician-pharmaceutical company relationships. This was a two-phase study consisting of qualitative research followed by a cross-sectional survey. Clinical experience logbooks of 280 second-year students in one school were analysed, and the themes that emerged were used to develop a survey that was administered to 308 third-year students from two medical schools. Survey results showed a 91.2% exposure to any type of marketing, and 56.8% of students were exposed to all classes of marketing methods studied. Deliberate targeting of students by pharmaceutical representatives, in particular, was correlated with being less sensitive to the negative effects of and having positive opinions about interactions with pharmaceutical companies. The vast majority of students are exposed to drug marketing in primary care settings, and may become more vulnerable to that strategy. Considering that medical students are vulnerable and are targeted deliberately by pharmaceutical companies, interventions aimed at developing skills in the rational use of medicines and in strategies for coping with drug marketing should be devised.

Development of a method to investigate medical students' perceptions of their personal and professional development

Personal and Professional Development (PPD) is now key to the undergraduate medical curriculum and requires provision of appropriate learning experiences. In order to achieve this, it is essential that we ascertain students' perceptions of what is important in their PPD. We required a methodological approach suitable for a large medical school, which defines constructs used by the students to describe their PPD, and is not constrained by a researcher's predetermined line of questioning. It should also quantify the saliencies of these constructs in the student population and indicate how they gauge their own PPD. The instrument should also be suitable for administration at key stages of the students' learning experience. Here we describe the first stages in developing a novel method, which fulfils these requirements. It is based on a modified self repertory grid, the "Ideal Self" Inventory. All first year students (N = 379), provided five descriptors of a "good medical student" and of a not very good medical student, which generated 1,531 'ideal' qualities. To define underlying themed constructs, 49 randomly selected descriptors, were grouped together by self selected students (n = 55), using commonly held assumptions. Frequency of item co-occurrence was tabulated by multidimensional scaling. Themed clusters of 'ideal' qualities, defined by hierarchical cluster analysis, were overlaid onto the multidimensional scaling to generate a concept map. This revealed seven themed constructs; Personal Welfare, Time and Self Management Committed Work Ethic, Learning Skills, Personal Development/Reflection, Personal and Professional Conduct and Teamwork. We then analysed the 1,531 'ideal' qualities, by determining the frequency with which students used each construct and the proportion of students who used a construct at least once. Personal and Professional Conduct, Committed Work Ethic and Time and Self Management were the most frequently used, implying that they were the most salient for the first year students.