How can experience in clinical and community settings contribute to early medical education? A BEME systematic review

Developing a patient focussed professional identity: an exploratory investigation of medical students' encounters with patient partnership in learning

Patient encounters are central to the provision of learning opportunities for medical students and their development as medical professionals. The primary aim of the study reported in this paper was to discover how partnering medical students with patients with chronic illness in undergraduate learning influenced the development of a patient centred professional identity and professionalism. An exploratory interpretive research design was used to address the research aim within a patient partner program (P3). Three qualitative data collection methods were used: (1) focus groups (2) extended response questionnaire and (3) semi-structured interviews. Data were coded and analysed thematically. The professional identity of medical students is constructed along traditional lines in the preclinical years. Patient-partnership offers a disruption to this development by way of an intersection with patients with chronic illness which potentially allows meaningful construction of what a patient-centred identity should be. This point of reflection provides an opportunity to engage at a higher level in medical identity development and professionalism. The findings discussed in this paper further stimulate the patient-centred agenda by understanding the conflict associated with the student-patient nexus in medical education and its potential for building professionalism and a patient-centred professional identity. To continue the drive for a patient-centred professional identity there must be ongoing engagement with patients in medical education, preferably commencing early in a student's journey so that it becomes the expected norm. This study has highlighted that a true patient-centred emphasis is being encountered too late in their socialisation process.

The impact of an early_exposure program on medical students' interest in and knowledge of rural medical practices: a questionnaire survey

BACKGROUND

Many medical students in Japan were brought up in urban areas, thus rural medical practice is often unfamiliar to them. The University of Tsukuba created a one-day early_exposure program to provide freshman students with experience in rural practices. This study was designed to clarify how this one-day early_exposure program affected medical students' attitudes toward and knowledge of rural practices.

FINDINGS

First-year medical students (n = 103) were assigned to one of seven rural clinics in which they experienced rural practice for one day. A pre- and post-program questionnaire, rated on a 5-point Likert scale, was administered to assess students' interest in and knowledge of rural medical practice, with higher scores indicating greater interest and knowledge. Respondents who gave answers of 4 or 5 were defined as having high interest and knowledge. One hundred and one (98.1%) responses were received from students. After the program, the percentage of students interested in rural medical practices was increased (pre- and post-program: 39.0% and 61.0%, respectively; P < .001), as was the number of students who wanted to become physicians in a rural medical practice (pre- and post-program: 53.0% and 73.0%, respectively; P < .01).

CONCLUSIONS

Our one-day early_exposure program demonstrated a positive impact on medical students' interest in and knowledge of rural medical practice. Further follow-up surveys are needed to clarify whether these effects are sustained long-term.

Community-based clinical education increases motivation of medical students to medicine of remote area: comparison between lecture and practice

In this study, we administered a questionnaire to medical students to evaluate the effect of community-based clinical education on their attitudes to community medicine and medicine in remote area. Questionnaires were given 4 times to all the students from first-year to sixth-year. Of 95 students, 65 students (68.4%) who completed all questionnaires, were used in this study. The intensity of students' attitudes was estimated by using visual analogue scale. The intensity of interest, a sense of fulfillment and passion in medicine of remote area was significantly increased after the community-based practice. On the other hand, the level of understanding in medicine in remote area was increased by the lecture not by the practice. The intensity of desire both to become a generalist and a specialist was significantly increased when the grade went up. Most of sixth-year students desired to have abilities of a generalist and a specialist simultaneously. This study shows that the community-based practice is more meaningful in increasing motivation in medicine in remote area than the lecture, and suggests that it is important to prepare more courses to experience community medicine to increase the number of physicians who desire to work in remote area.

Who wants to become a general practitioner? Student and curriculum factors associated with choosing a GP career--a multivariable analysis with particular consideration of practice-orientated GP courses

OBJECTIVE

Because of the increasing shortage of general practitioners (GPs) in many countries, this study aimed to explore factors related to GP career choice in recent medical graduates. Particular focus was placed on the impact of specific practice-orientated GP courses at different stages of the medical undergraduate curriculum.

DESIGN

Observational study. Multivariable binary logistic regression was used to reveal independent associations with career choice.

SETTING

Leipzig Medical School, Germany.

SUBJECTS

659 graduates (response rate = 64.2%).

MAIN OUTCOME MEASURE

Choice of general practice as a career.

RESULTS

Six student-associated variables were found to be independently related to choice of general practice as a career: age, having family or friends in general practice, consideration of a GP career at matriculation, preference for subsequent work in a rural or small-town area, valuing the ability to see a broad spectrum of patients, and valuing long-term doctor-patient relationships. Regarding the curriculum, after adjustment independent associations were found with a specific pre-clinical GP elective (OR = 2.6, 95% CI 1.3-5.3), a four-week GP clerkship during the clinical study section (OR = 2.6, 95% CI 1.3-5.0), and a four-month GP clinical rotation during the final year (OR = 10.7, 95% CI 4.3-26.7). It was also found that the work-related values of the female participants were more compatible with those of physicians who opt for a GP career than was the case for their male colleagues.

CONCLUSION

These results support the suggestion that a practice-orientated GP curriculum in both the earlier and later stages of undergraduate medical education raises medical schools' output of future GPs. The findings are of interest for medical schools (curriculum design, admission criteria), policy-makers, and GPs involved in undergraduate medical education. More research is needed on the effectiveness of specific educational interventions in promoting interest in general practice as a career.

The capability approach for medical education: AMEE Guide No. 97

The capability approach, with its origins in economic and human development work, has a focus on the freedom of persons to make choices about how they wish to lead a valued life. There has been increasing recognition within general education that the capability approach offers a theoretical and practical framework to both implement and evaluate educational interventions that are designed to increase social justice, such as widening participation. There is great potential for the capability approach to also offer medical education a creative way for changing and evaluating curricula, with an emphasis on the teacher facilitating students to achieve their potential by recognising their aspirations and challenging the constraining factors to achieve their aspirations.

The effect of different levels of realism of context learning on the prescribing competencies of medical students during the clinical clerkship in internal medicine: an exploratory study

PURPOSE

The aim of this study is to evaluate the effect of different levels of realism of context learning on the prescribing competencies of medical students during the clinical clerkship in internal medicine.

METHODS

Between 2001 and 2007, 164 medical students took part in the prospective explorative study during their clinical clerkship in internal medicine at the VU University Medical Center, Amsterdam, The Netherlands. In a fixed order, each student had to formulate a treatment plan for a real patient in three situations of increasing realism: a minimal level (studying a patient record), medium level (preparing for a therapeutic consultation), and optimal level (preparing for and performing a therapeutic consultation with the patient).

RESULTS

In comparison to studying a patient record (minimal context level), preparing a therapeutic consultation (medium context) improved four of the six steps of the WHO six-step plan. Preparing and performing a therapeutic consultation with a real patient (optimal context) further improved three essential prescribing competencies, namely checking for contraindications and interactions, prescription writing, and instructions to the patient.

CONCLUSION AND RECOMMENDATIONS

The results of this first explorative study suggest that enrichment of the learning context (responsibility for patient care) might be an important factor to improve the training of rational prescribing skills of medical students during their clinical clerkship in internal medicine. Clinical (pharmacology) teachers should be aware that seemingly small adaptations in the learning context of prescribing training during clinical clerkships (i.e., with or without involvement with and responsibility for patient care) may have relatively large impact on the development of prescribing competencies of our future doctors.

The current provision of community-based teaching in UK medical schools: an online survey and systematic review

OBJECTIVE

To evaluate the current provision and outcome of community-based education (CBE) in UK medical schools.

DESIGN AND DATA SOURCES

An online survey of UK medical school websites and course prospectuses and a systematic review of articles from PubMed and Web of Science were conducted. Articles in the systematic review were assessed using Rossi, Lipsey and Freeman's approach to programme evaluation.

STUDY SELECTION

Publications from November 1998 to 2013 containing information related to community teaching in undergraduate medical courses were included.

RESULTS

Out of the 32 undergraduate UK medical schools, one was excluded due to the lack of course specifications available online. Analysis of the remaining 31 medical schools showed that a variety of CBE models are utilised in medical schools across the UK. Twenty-eight medical schools (90.3%) provide CBE in some form by the end of the first year of undergraduate training, and 29 medical schools (93.5%) by the end of the second year. From the 1378 references identified, 29 papers met the inclusion criteria for assessment. It was found that CBE mostly provided advantages to students as well as other participants, including GP tutors and patients. However, there were a few concerns regarding the lack of GP tutors' knowledge in specialty areas, the negative impact that CBE may have on the delivery of health service in education settings and the cost of CBE.

CONCLUSIONS

Despite the wide variations in implementation, community teaching was found to be mostly beneficial. To ensure the relevance of CBE for 'Tomorrow's Doctors', a national framework should be established, and solutions sought to reduce the impact of the challenges within CBE.

STRENGTHS AND LIMITATIONS OF THIS STUDY

This is the first study to review how community-based education is currently provided throughout Medical Schools in the UK. The use of Rossi, Lipsey and Freeman's method of programme evaluation means that the literature was analysed in a consistent and comprehensive way. However, a weakness is that data from the online survey was obtained from online medical school prospectuses. This means the data may be incomplete or out of date. Data in the literature review may also be skewed by publication bias.

How and what do medical students learn in clerkships? Experience based learning (ExBL)

Clerkship education has been called a 'black box' because so little is known about what, how, and under which conditions students learn. Our aim was to develop a blueprint for education in ambulatory and inpatient settings, and in single encounters, traditional rotations, or longitudinal experiences. We identified 548 causal links between conditions, processes, and outcomes of clerkship education in 168 empirical papers published over 7 years and synthesised a theory of how students learn. They do so when they are given affective, pedagogic, and organisational support. Affective support comes from doctors' and many other health workers' interactions with students. Pedagogic support comes from informal interactions and modelling as well as doctors' teaching, supervision, and precepting. Organisational support comes from every tier of a curriculum. Core learning processes of observing, rehearsing, and contributing to authentic clinical activities take place within triadic relationships between students, patients, and practitioners. The phrase 'supported participation in practice' best describes the educational process. Much of the learning that results is too tacit, complex, contextualised, and individual to be defined as a set of competencies. We conclude that clerkship education takes place within relationships between students, patients, and doctors, supported by informal, individual, contextualised, and affective elements of the learned curriculum, alongside formal, standardised elements of the taught and assessed curriculum. This research provides a blueprint for designing and evaluating clerkship curricula as well as helping patients, students, and practitioners collaborate in educating tomorrow's doctors.

Let's talk about integration: a study of students' understandings of integration

Today, the knowledge concerning clinical reasoning is advanced enough to translate into curriculum interventions such as an integrated curriculum, in which science theory and clinical practice can be interwoven effectively. However, the interpretations of what integration means differ and the purpose of this study was to elicit how students understand integration. This study was carried out using an interpretative perspective. Medical students, in their 2nd year of study, were asked to apply basic science knowledge from all previous courses to clinical cases in an examination. Subsequent to the examination, focus group interviews were conducted. The interviews were audio recorded, transcribed and analysed by the use of qualitative content analysis. The analysis revealed how students comprehended integration: as the creation of wholeness, as relating new knowledge to core concepts, as reasoning, as application and as collaboration between teachers. The five categories were linked to three dimensions: intra-personal, inter-personal and organizational, each of which resonates with different theories of how expertise is developed. The outcome of this study adds to our understanding of how students conceptualize integration. The categories of 'integration' drawn out by the study are helpful in promoting further discussion of how eliciting students' own reports of cognition and may help the ongoing design of curricula by putting students at the center of the curriculum design process.

Clinical practice and self-awareness as determinants of empathy in undergraduate education: a qualitative short survey at three medical schools in Germany

STUDY AIM

Physician empathy constitutes an outcome-relevant aim of medical education. Yet, the factors promoting and inhibiting physician empathy have not yet been extensively researched, especially in Germany. In this study, we explored German medical students' views of the factors promoting and inhibiting their empathy and how their experiences were related to their curricula.

METHODS

A qualitative short survey was conducted at three medical schools: Bochum University, the University of Cologne and Witten/Herdecke University. Students were invited to complete an anonymous written questionnaire comprised of open-ended questions inquiring about the educational content of and situations during their medical education that positively or negatively impacted their empathy. Data were analyzed through qualitative content analysis according to the methods of Green and Thorogood.

RESULTS

A total of 115 students participated in the survey. Respondents reported that practice-based education involving patient contact and teaching with reference to clinical practice and the patient's perspective improved their empathy, while a lack of these inhibited it. Students' internal reactions to patients, such as liking or disliking a patient, prejudice and other attitudes, were also considered to influence their empathy. Although each of the three schools takes a different approach to teaching interpersonal skills, no relevant differences were found in their students' responses concerning the possible determinants of empathy.

CONCLUSION

Providing more training in practice and more contact with patients may be effective ways of promoting student empathy. Students need support in establishing therapeutic relationships with patients and in dealing with their own feelings and attitudes. Such support could be provided in the form of reflective practice training in order to promote self-awareness. More research is needed to evaluate these hypothetical conclusions.

Cultural sensitivity or professional acculturation in early clinical experience?

AIM

This study aimed to explore the early clinical experience of medical students following the adaptation of an Early Patient Contact curriculum from a European culture in Ireland to an Arab culture in Bahrain.

METHODS

Medical students in Bahrain took part in an Early Patient Contact module modelled on a similar module from a partner medical school in Ireland. We used a qualitative approach employing thematic analysis of 54 student reflective logbooks. Particular attention was placed on reflections of cultural influences of experience in the course.

RESULTS

Medical students undergoing this module received reported documented benefits of early clinical experience. However, students in Bahrain were exposed to cultural norms of the local Arab society including gender values, visiting the homes of strangers, language barriers and generous hospitality that led to additional challenges and learning for the medical students in acculturating to norms of the medical profession.

CONCLUSION

Modules intended for curriculum adaptation between two cultures would be best served by a group of "core" learning outcomes with "secondary" outcomes culturally appropriate to each site. Within the context of the Arab culture, early clinical experience has the added benefit of allowing students to learn about both local and professional cultural norms, thereby facilitating integration of these two cultures.

Comprehensive Healthcare module: medical and pharmacy students' shared learning experiences

INTRODUCTION

The Comprehensive Healthcare (CHC) module was developed to introduce pre-clinical medical and pharmacy students to the concept of comprehensive healthcare. This study aims to explore their shared learning experiences within this module.

METHODOLOGY

During this module, medical and pharmacy students conducted visits to patients' homes and to related community-based organisations in small groups. They were required to write a reflective journal on their experiences regarding working with other professions as part of their module assessment. Highly scored reflective journals written by students from the 2011/2012 academic session were selected for analysis. Their shared learning experiences were identified via thematic analysis. We also analysed students' feedback regarding the module.

RESULTS

Analysis of 25 selected reflective journals revealed several important themes: 'Understanding of impact of illness and its relation to holistic care', 'Awareness of the role of various healthcare professions' and 'Generic or soft skills for inter-professional collaboration'. Although the primary objective of the module was to expose students to comprehensive healthcare, the students learnt skills required for future collaborative practice from their experiences.

DISCUSSION

The CHC module provided early clinical exposure to community-based health issues and incorporated some elements of inter-professional education. The students learnt about the roles of other healthcare professions and acquired soft skills required for future collaborative practice during this module.

Assessing 3rd year medical students' interprofessional collaborative practice behaviors during a standardized patient encounter: A multi-institutional, cross-sectional study

BACKGROUND

To understand how third-year medical student interprofessional collaborative practice (IPCP) is affected by self-efficacy and interprofessional experiences (extracurricular experiences and formal curricula).

METHODS

The authors measured learner IPCP using an objective structured clinical examination (OSCE) with a standardized nurse (SN) and standardized patient (SP) during a statewide clinical performance examination. At four California medical schools from April to August 2012, SPs and SNs rated learner IPCP (10 items, range 0-100) and patient-centered communication (10 items, range 0-100). Post-OSCE, students reported their interprofessional self-efficacy (16 items, 2 factors, range 1-10) and prior extracurricular interprofessional experiences (3 items). School representatives shared their interprofessional curricula during guided interviews.

RESULTS

Four hundred sixty-four of 530 eligible medical students (88%) participated. Mean IPCP performance was 79.6 ± 14.1 and mean self-efficacy scores were 7.9 (interprofessional teamwork) and 7.1 (interprofessional feedback and evaluation). Seventy percent of students reported prior extracurricular interprofessional experiences; all schools offered formal interprofessional curricula. IPCP was associated with self-efficacy for interprofessional teamwork (β = 1.6, 95% CI [0.1, 3.1], p = 0.04) and patient-centered communication (β = 12.5, 95% CI [2.7, 22.3], p = 0.01).

CONCLUSIONS

Medical student IPCP performance was associated with self-efficacy for interprofessional teamwork and patient-centered communication. Increasing interprofessional opportunities that influence medical students' self-efficacy may increase engagement in IPCP.

Recommendations for undergraduate training in the primary care sector--position paper of the GMA-Primary Care Committee

During their studies to become medical professionals, all students are obliged to become familiar with various aspects of primary care. The aim is to provide all students with a high quality training which ensures the best possible cooperation across all sectors of the medical system.

Primary care comprises the primary use of the medical service by an unfiltered set of patients as well as continued patient care – including home-care.

This position paper was developed together with representatives of the German Society of University Teachers of General Practice (GHA), the German Society for Ambulatory General Paediatrics (DGAAP), the German Society of General Practice and Family Medicine (DEGAM) and the German Society for Internal Medicine (DGIM).

It includes recommendations for teaching in the field of primary care in four different types of internships such as preclinical work experience (“Hospitation”), 4-week clinical traineeships of a casual nature (“Famulatur”) and 2-week courses of structured and assessed clinical training (“Blockpraktikum”) as well as a broad-based 4-month elective clinical placement in the final year (known as a practical year, “PJ”).

The recommendations encompass structural and process criteria for internships in different general practices.

In addition, for the first time recommendations for teaching on campus – in the fields of general medicine, paediatrics, numerous cross-sectional areas and other clinical fields, but also for clinical skills training – are set down here.

In this position paper the intention is to demonstrate the possible ways in which more aspects of primary care could be integrated into undergraduate medical training.

What primary care physician teachers need to sustain community based education in Japan

BACKGROUND

Community based education (CBE), defined as "a means of achieving educational relevance to community needs and, consequently, of implementing a community oriented educational program," is reported to be useful for producing rural physicians in Western countries. However, why some physicians withdraw from their teaching roles is not well known, especially in Asian countries. The aim of this study was to clarify the requisites and obstacles for taking part in CBE.

METHODS

WE COMBINED TWO STEPS: preliminary semi-structured interviews followed by workshop discussions. First of all, we interviewed four designated physicians (all male, mean age 48 years) working in one rural area of Japan, with less than 10,000 residents. Secondly, we held a workshop at the academic conference of the Japan Primary Care Association. Fourteen participants attending the workshop (seven male physicians, mean age 45 years, and seven medical students (one female and six male), mean age 24 years) were divided into two groups and their opinions were summarized.

RESULTS

In the first stage, we extracted three common needs from interviewees; 1. Sustained significant human relationships; 2. Intrinsic motivation; and 3. Tangible rewards. In the second stage, we summarized three major problems from three different standpoints; A. Preceptors' issues: more educational knowledge or skills, B. Learner issues: role models in rural areas, and C. System issues: supportive educational system for raising rural physicians.

CONCLUSIONS

Our research findings revealed that community physicians require non-monetary support or intrinsic motivation for their CBE activities, which is in accordance with previous Western studies. In addition, we found that system support, as well as personal support, is required. Complementary questionnaire surveys in other Asian countries will be needed to validate our results.

Legitimate workplace roles and activities for early learners

OBJECTIVES

Given the calls for earlier student engagement in clinical experiences, educators are challenged to define roles for pre-clerkship students that enable legitimate participation in clinical practice. This study aimed to determine the student roles and activities, as well as the clinic characteristics, that allow early student engagement within a specific clinical experience.

METHODS

The authors conducted semi-structured interviews in December 2011 and January 2012 with a purposive sample of medical student and faculty volunteers at student-run clinics (SRCs). They were asked to discuss and compare student roles in SRCs with those in the core curriculum. An inductive approach and iterative process were used to analyse the interview transcripts. Themes identified from initial open coding were organised using the sensitising concepts of workplace learning and communities of practice and subsequently applied to code all transcripts.

RESULTS

A total of 22 medical students and four faculty advisors were interviewed. Thematic analysis revealed pre-clerkship student roles in direct patient care (patient triage, history and physical examinations, patient education, laboratory and immunisation procedures) and in clinic management (patient follow-up, staff management, quality improvement). Students took ownership of patients and occupied central roles in the function of the clinic, with faculty staff serving as peripheral resources. Clinic-related features supporting this degree of legitimate participation included defined scopes of practice, limited presenting illnesses, focused student training, and clear protocols and operations manuals.

CONCLUSIONS

Pre-clerkship students are capable of legitimately participating in patient care experiences to an extent not usually available to them. The SRC represents one example of how early clinical experiences in the core curriculum might be transformed through the provision of patient care activities of narrow scope.

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.

A systematic literature review of undergraduate clinical placements in underserved areas

CONTEXT

The delivery of undergraduate clinical education in underserved areas is increasing in various contexts across the world in response to local workforce needs. A collective understanding of the impact of these placements is lacking. Previous reviews have often taken a positivist approach by only looking at outcome measures. This review addresses the question: What are the strengths and weaknesses for medical students and supervisors of community placements in underserved areas?

METHODS

A systematic literature review was carried out by database searching, citation searching, pearl growing, reference list checking and use of own literature. The databases included MEDLINE, EMBASE, PsycINFO, Web of Science and ERIC. The search terms used were combinations and variations of four key concepts exploring general practitioner (GP) primary care, medical students, placements and location characteristics. The papers were analysed using a textual narrative synthesis.

FINDINGS

The initial search identified 4923 results. After the removal of duplicates and the screening of titles and abstracts, 185 met the inclusion criteria. These full articles were obtained and assessed for their relevance to the research question; 54 were then included in the final review. Four main categories were identified: student performance, student perceptions, career pathways and supervisor experiences.

CONCLUSIONS

This review reflects the emergent qualitative data as well as the quantitative data used to assess initiatives. Underserved area placements have produced many beneficial implications for students, supervisors and the community. There is a growing amount of evidence regarding rural, underserved areas, but little in relation to inner city, deprived areas, and none in the UK.

Premedical students' experiences in community-oriented primary care

PURPOSE

Medical students must be taught community medicine to understand common community-wide health problems and develop the skills that are needed to solve them. In this study, community-oriented primary care (COPC) projects were undertaken by premedical students in a community medicine course, and their experience was assessed.

METHODS

We analyzed the final reports of 570 premedical students who completed their community group projects from 2000 to 2012.

RESULTS

Eighty-nine community projects were completed by the students. The average number of students per project was 6.3 (range, 3-9). The total number of project themes was 39. Sex education for high school students, guidance on learning for low socioeconomic children, and education on smoking cessation for high school students were the most frequently selected topics. The most common subjects in the projects were high school students, preschool children, elderly people, and hospice patients. With regard to methodology, the students administered questionnaires in 58 cases and held health education programs in 48 cases. In 42 cases, students used social welfare-related community resources. In their final reports, many students felt that an understanding of their identities as future physicians and of the health care and social welfare systems was meaningful.

CONCLUSION

Premedical students' experiences in COPC projects varied and were positive. Teaching community medicine in a premedical course increased students' confidence with their future role as compassionate, socially responsible physicians and their understanding of community resources in a health care network.

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.

Foundation doctors' views of medical professionalism

The views of Foundation Years 1 and 2 doctors on medical professionalism were investigated using focus groups, in respect of definitions and components, teaching, learning and assessment. They were able to define and identify the components of medical professionalism, as well as components that could be taught. They felt medical professionalism was poorly taught and assessed. They recognised the dangers the online environment posed to medical professionalism but felt public expectations for doctors could at times be unrealistic. The profile, teaching and assessment of medical professionalism need to be improved. This can be achieved by teaching and assessing it as a standalone entity rather that within medical ethics as it is currently taught, and raising its profile to that of academic subjects.

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.

Evidence-based medicine training in undergraduate medical education: a review and critique of the literature published 2006-2011

PURPOSE

To characterize recent evidence-based medicine (EBM) educational interventions for medical students and suggest future directions for EBM education.

METHOD

The authors searched the MEDLINE, Scopus, Educational Resource Information Center, and Evidence-Based Medicine Reviews databases for English-language articles published between 2006 and 2011 that featured medical students and interventions addressing multiple EBM skills. They extracted data on learner and instructor characteristics, educational settings, teaching methods, and EBM skills covered.

RESULTS

The 20 included articles described interventions delivered in 12 countries in classroom (75%), clinic (25%), and/or online (20%) environments. The majority (60%) focused on clinical students, whereas 30% targeted preclinical students and 10% included both. EBM skills addressed included recognizing a knowledge gap (20%), asking a clinical question (90%), searching for information (90%), appraising information (85%), applying information (65%), and evaluating practice change (5%). Physicians were most often identified as instructors (60%); co-teachers included librarians (20%), allied health professionals (10%), and faculty from other disciplines (10%). Many studies (60%) included interventions at multiple points during one year, but none were longitudinal across students' tenures. Teaching methods varied. Intervention efficacy could not be determined.

CONCLUSIONS

Settings, learner levels and instructors, teaching methods, and covered skills differed across interventions. Authors writing about EBM interventions should include detailed descriptions and employ more rigorous research methods to allow others to draw conclusions about efficacy. When designing EBM interventions, educators should consider trends in medical education (e.g., online learning, interprofessional education) and in health care (e.g., patient-centered care, electronic health records).

Communities’ views, attitudes and recommendations on community-based education of undergraduate Health Sciences students in South Africa: A qualitative study

Background

Medical and Health Sciences students in South Africa undertake community-based education (CBE). Health professionals based at host sites are jointly responsible for training of these students in conjunction with university staff. This study explored the communities’ views, attitudes and recommendations regarding CBE undertaken by these students, in order to improve the quality of community support for these programmes.

Method

A qualitative descriptive study was conducted at CBE placement sites of students from the Faculties of Health Sciences of the University of Limpopo (UL), University of KwaZulu-Natal (UKZN) and University of the Western Cape (UWC) during 2010 and 2011. Focus group discussions were held with site facilitators, community leaders and patients, and interviews were audio recorded, transcribed and translated into English where necessary. Data were analysed using NVivo (version 9).

Findings

CBE was seen to benefit communities, students and host institutions as there was perceived improvement of service delivery, better referral to hospitals and reduction of workloads on site staff. CBE was also seen as having potential for recruiting professionals who have better orientation to the area, and for motivating school pupils for a career in health sciences. Students acquired practical skills and gained confidence and experience. Challenges included poor communication between universities and host sites, burden of student teaching on site facilitators, cultural and religious sensitivity of students and language barriers.

Conclusion

The study revealed that communities have an important role to play in the CBE of future health care professionals. CBE activities could be better organised and managed through formalised partnerships.

What are the benefits of early patient contact?--A comparison of three preclinical patient contact settings

BACKGROUND

Despite increasing attention to providing preclinical medical students with early patient experiences, little is known about associated outcomes for students. The authors compared three early patient experiences at a large American medical school where all preclinical students complete preceptorships and weekly bedside clinical-skills training and about half complete clinical, community-based summer immersion experiences. The authors asked, what are the relative outcomes and important educational components for students?

METHODS

Medical students completed surveys at end of second year 2009-2011. In 2009, students compared/contrasted two of three approaches; responses framed later survey questions. In 2010 and 2011, students rated all three experiences in relevant areas (e.g., developing comfort in clinical setting). Investigators performed qualitative and quantitative analyses.

RESULTS

Students rated bedside training more highly for developing comfort with clinical settings, one-on-one clinical-skills training, feedback, active clinical experience, quality of clinical training, and learning to be part of a team. They rated community clinical immersion and preceptorships more highly for understanding the life/practice of a physician and career/specialty decisions.

CONCLUSIONS

Preclinical students received different benefits from the different experiences. Medical schools should define objectives of early clinical experiences and offer options accordingly. A combination of experiences may help students achieve clinical and team comfort, clinical skills, an understanding of physicians' lives/practices, and broad exposure for career decisions.

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.

Are medical educators following General Medical Council guidelines on obesity education: if not why not?

BACKGROUND

Although the United Kingdom's (UK's) General Medical Council (GMC) recommends that graduating medical students are competent to discuss obesity and behaviour change with patients, it is difficult to integrate this education into existing curricula, and clinicians report being unprepared to support patients needing obesity management in practice. We therefore aimed to identify factors influencing the integration of obesity management education within medical schools.

METHODS

Twenty-seven UK and Irish medical school educators participated in semi-structured interviews. Grounded theory principles informed data collection and analysis. Themes emerging directly from the dataset illustrated key challenges for educators and informed several suggested solutions.

RESULTS

Factors influencing obesity management education included: 1) Diverse and opportunistic learning and teaching, 2) Variable support for including obesity education within undergraduate medical programmes, and 3) Student engagement in obesity management education. Findings suggest several practical solutions to identified challenges including clarifying recommended educational agendas; improving access to content-specific guidelines; and implementing student engagement strategies.

CONCLUSIONS

Students' educational experiences differ due to diverse interpretations of GMC guidelines, educators' perceptions of available support for, and student interest in obesity management education. Findings inform the development of potential solutions to these challenges which may be tested further empirically.

Early community-based family practice elective positively influences medical students' career considerations--a pre-post-comparison

Background

Demographic change and recruitment problems in family practice are increasingly threatening an adequate primary care workforce in many countries. Thus, it is important to attract young physicians to the field. The purpose of the present study was to examine the effect of an early community-based 28-h family practice elective with one-to-one mentoring on medical students’ consideration of family practice as a career option, their interest in working office-based, and several perceptions with regard to specific aspects of a family physician’s work.

Methods

First- and second-year medical students completed questionnaires before and after a short community-based family practice elective, consisting of a preparatory course and a community-based practical experience with one-to-one mentoring by trained family physicians.

Results

We found a significantly higher rate of students favoring family practice as a career option after the elective (32.7% vs. 26.0%, p = 0.039). Furthermore, the ranking of family practice among other considered career options improved (p = 0.002). Considerations to work office-based in the future did not change significantly. Perceptions regarding a family physician’s job changed positively with regard to the possibility of long-term doctor-patient relationships and treatment of complex disease patterns. The majority of the students described identification with the respective family physician tutor as a professional role model and an increased interest in the specialty.

Conclusions

Our results indicate that a short community-based family practice elective early in medical education may positively influence medical students’ considerations of a career in family practice. Furthermore, perceptions regarding the specialty with significant impact on its attractiveness may be positively adjusted. Further research is needed to evaluate the influence of different components of a family practice curriculum on the de facto career decisions of young physicians after graduation.

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.

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.

Teaching and assessing veterinary professionalism

The teaching and assessment of professional behaviors and attitudes are important components of veterinary curricula. This article aims to outline some important considerations and concepts which will be useful for veterinary educators reviewing or developing this topic. A definition or framework of veterinary professionalism must be decided upon before educators can develop relevant learning outcomes. The interface between ethics and professionalism should be considered, and both clinicians and ethicists should deliver professionalism teaching. The influence of the hidden curriculum on student development as professionals should also be discussed during curriculum planning because it has the potential to undermine a formal curriculum of professionalism. There are several learning theories that have relevance to the teaching and learning of professionalism; situated learning theory, social cognitive theory, adult learning theory, reflective practice and experiential learning, and social constructivism must all be considered as a curriculum is designed. Delivery methods to teach professionalism are diverse, but the teaching of reflective skills and the use of early clinical experience to deliver valid learning opportunities are essential. Curricula should be longitudinal and integrated with other aspects of teaching and learning. Professionalism should also be assessed, and a wide range of methods have the potential to do so, including multisource feedback and portfolios. Validity, reliability, and feasibility are all important considerations. The above outlined approach to the teaching and assessment of professionalism will help ensure that institutions produce graduates who are ready for the workplace.

Workplace learning in veterinary education: a sociocultural perspective

Veterinary practice is a broad sphere of professional activity encompassing clinical activity and other vocational opportunities conducted in rapidly changing contemporary social conditions. Workplace learning is an important but resource-intensive component of educating students for practice. This conceptual article argues that literature on workplace learning in the veterinary context is dominated by descriptive accounts and that there is a dearth of theoretically informed research on this topic. Framing veterinary practice as a social, relational, and discursive practice supports the use of workplace learning theories developed from a sociocultural perspective. Situated learning theory, with its associated concepts of communities of practice and legitimate peripheral participation, and workplace learning theory focused on workplace affordances and learner agency are discussed. Two composite examples of student feedback from veterinary clinical learning illustrate the concepts, drawing out such themes as the roles of teachers and learners and the assessment of integrated practice. The theoretical perspective described in this article can be used to inform development of models of workplace learning in veterinary clinical settings; relevant examples from medical education are presented.

Integrative medical education: educational strategies and preliminary evaluation of the Integrated Curriculum for Anthroposophic Medicine (ICURAM)

OBJECTIVES

the development and preliminary evaluation of a new medical program aimed at educating students in patient-centered integrative care and developing appropriate educational strategies.

METHODS

The Integrated Curriculum for Anthroposophic Medicine (ICURAM) was developed with modules on anthroposophic medicine integrated into the full 6 years of the regular medical curriculum. The educational strategy is the ESPRI(2)T approach, combining Exploratory learning, Supported participation, Patient-based learning, Reflective practice, Integrated learning, an Integrative approach and Team-based learning. The student participation, assessed based on the number of credit points earned per year (ctp/year) through the ICURAM (1 ctp=30 h workload), served as a preliminary indicator of student interest.

RESULTS

Of the 412 55%medical students participated in the program: 16% full participation (≥ 4 ctp/year), 18% partial participation (1-3.99 ctp/year) and 22% occasional participation (0.25-0.99 ctp/year). The amount of additional workload taken on by students was between 7.8h/year for occasional participants, 33 h/year for partial participants and 84 h/year for full participants.

CONCLUSION

More than half of medical students were willing to invest a significant amount of additional time in the optional program.

PRACTICE IMPLICATIONS

An integrative medical curriculum with a student-centered educational strategy seems to be of interest to most medical students.

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.

Beyond the ward and waiting room: a community-based non-clinical placement programme for Australian medical students

BACKGROUND

Placement programmes are essential to medical education but almost invariably take place in clinical settings, even when community based. Australia's Monash University, however, has included in its core MBBS curriculum a non-clinical placement for second-year students, the Community Based Practice (CBP) programme. This involves partnerships with community organisations that are mostly non-medical. The programme includes a health promotion (HP) component where students respond to a HP or support need nominated by their placement organisation. Though inspired by community-based medical education (CBME) programmes in England and South Australia's Flinders University, its non-clinical focus represents a creative development in Australian medical education.

METHODS

This article describes the programme, explores its place within CBME and outlines the results of its analysis of student responses using SPSS and NVivo.

RESULTS

The evidence showed development of students' communication skills; increased understanding and appreciation of the mainly non-medical health support infrastructure in local communities; increased understanding of HP and community health support at the local level; and contributions to the placement organisations through small-scale research or health support projects.

CONCLUSION

Placement programmes such as this can significantly contribute to medical education, especially in supporting health in local communities and understanding the needs of the marginalised.

Impact of preclinical exposure to organ donation on knowledge and attitudes of medical students

CONTEXT

Medical students receive little exposure to organ donation and procurement programs.

OBJECTIVE

To describe a student-run elective and its effect on participants' knowledge about and attitudes toward organ donation.

INTERVENTION

Preclinical students interacted directly with donor families, organ recipients, and donation representatives; many participated in an organ procurement with the surgical team.

DESIGN

Between 2005 and 2007, 13 students who participated in the elective and a procurement were compared with 72 students who took the elective but did not participate in a procurement and with 22 control students. Students who participated in a procurement wrote reflections about their experience. In 2010, 15 first-year students who participated in the elective and a procurement and 59 randomly selected control students completed a previously validated measure.

OUTCOME

Themes included awe, surgical procedures, learning opportunities, and brain death. Regardless of procurement participation, the elective participants from 2005 to 2007 reported higher 4-item knowledge scores (P<.001) than control students reported, but their 4-item attitude scores did not differ (P = .21). The 2010 students did not differ from control students in their number of correct responses to the 20 knowledge questions (P = .48) or their individual responses to each of the 14 attitude questions (all P>.05).

RESULTS

Although elective participants reflected positively on their experiences and professed greater knowledge than control students via a researcher-made tool, these results were not sustained with a previously validated measure. These results point to the need for careful elective design and the need for more accurate measures to study the effectiveness of such interventions.

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.

Have motivation theories guided the development and reform of medical education curricula? A review of the literature

PURPOSE

Educational psychology indicates that learning processes can be mapped on three dimensions: cognitive (what to learn), affective or motivational (why learn), and metacognitive regulation (how to learn). In a truly student-centered medical curriculum, all three dimensions should guide curriculum developers in constructing learning environments. The authors explored whether student motivation has guided medical education curriculum developments.

METHOD

The authors reviewed the literature on motivation theory related to education and on medical education curriculum development to identify major developments. Using the Learning-Oriented Teaching model as a framework, they evaluated the extent to which motivation theory has guided medical education curriculum developers.

RESULTS

Major developments in the field of motivation theory indicate that motivation drives learning and influences students' academic performance, that gender differences exist in motivational mechanisms, and that the focus has shifted from quantity of motivation to quality of motivation and its determinants, and how they stimulate academic motivation. Major developments in medical curricula include the introduction of standardized and regulated medical education as well as problem-based, learner-centered, integrated teaching, outcome-based, and community-based approaches. These curricular changes have been based more on improving students' cognitive processing of content or metacognitive regulation than on stimulating motivation.

CONCLUSIONS

Motivational processes may be a substantially undervalued factor in curriculum development. Building curricula to specifically stimulate motivation in students may powerfully influence the outcomes of curricula. The elements essential for stimulating intrinsic motivation in students, including autonomy support, adequate feedback, and emotional support, appear lacking as a primary aim in many curricular plans.

Preclinical students' experiences in early clerkships after skills training partly offered in primary health care centers: a qualitative study from Indonesia

BACKGROUND

Students may encounter difficulties when they have to apply clinical skills trained in their pre-clinical studies in clerkships. Early clinical exposure in the pre-clinical phase has been recommended to reduce these transition problems. The aim of this study is to explore differences in students' experiences during the first clerkships between students exclusively trained in a skills laboratory and peers for whom part of their skills training was substituted by early clinical experiences (ECE).

METHODS

Thirty pre-clinical students trained clinical skills exclusively in a skills laboratory; 30 peers received part of their skills training in PHC centers. Within half a year after commencing their clerkships all 60 students shared their experiences in focus group discussions (FGDs). Verbatim transcripts of FGDs were analyzed using Atlas-Ti software.

RESULTS

Clerkship students who had participated in ECE in PHC centers felt better prepared to perform their clinical skills during the first clerkships than peers who had only practiced in a skills laboratory. ECE in PHC centers impacted positively in particular on students' confidence, clinical reasoning, and interpersonal communication.

CONCLUSION

In the Indonesian setting ECE in PHC centers reduce difficulties commonly encountered by medical students in the first clerkships.

Preparedness for practice: the perceptions of medical graduates and clinical teams

BACKGROUND

Earlier research indicated that medical graduates feel unprepared to start work, and that this varies with medical school.

AIMS

To examine the extent to which graduates from different UK medical schools differed in their perceptions of preparedness for practice, and compare their perceptions with those of clinical team members.

METHOD

An anonymous questionnaire assessing perceptions of 53 aspects of preparedness was devised, and administered to the graduating cohorts of three medical schools: Newcastle (systems-based, integrated curriculum); Warwick (graduate-entry) and Glasgow (problem-based learning). In addition, a triangulating questionnaire was cascaded via ward managers to doctors, nurses and pharmacists who worked with new graduates in their first posts.

RESULTS

The response rate for the cohort questionnaire was 69% (479/698). The overall mean preparedness score was 3.5 (on a five-point scale), with no significant difference between schools. On individual items, there were large differences within each site, but smaller differences between sites. Graduates felt most prepared for aspects of working with patients and colleagues, history taking and examination. They felt least prepared for completing a cremation form, some aspects of prescribing, complex practical procedures and for applying knowledge of alternative and complementary therapies, and of the NHS. A total of 80 clinical team questionnaires were completed, similarly showing substantial variation within each site, but smaller differences between sites.

CONCLUSIONS

New doctors feel relatively unprepared for a number of aspects of practice, a perception shared by their colleagues. Although medical school has some effect on preparedness, greater differences are common across sites. Differences may reflect hidden influences common to all the schools, unintended consequences of national curriculum guidance or common traits in the graduate populations sampled. Further research is needed to identify the causes.

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.

Kirkpatrick's levels and education 'evidence'

OBJECTIVES

This study aims to review, critically, the suitability of Kirkpatrick's levels for appraising interventions in medical education, to review empirical evidence of their application in this context, and to explore alternative ways of appraising research evidence.

METHODS

The mixed methods used in this research included a narrative literature review, a critical review of theory and qualitative empirical analysis, conducted within a process of cooperative inquiry.

RESULTS

Kirkpatrick's levels, introduced to evaluate training in industry, involve so many implicit assumptions that they are suitable for use only in relatively simple instructional designs, short-term endpoints and beneficiaries other than learners. Such conditions are met by perhaps one-fifth of medical education evidence reviews. Under other conditions, the hierarchical application of the levels as a critical appraisal tool adds little value and leaves reviewers to make global judgements of the trustworthiness of the data.

CONCLUSIONS

Far from defining a reference standard critical appraisal tool, this research shows that 'quality' is defined as much by the purpose to which evidence is to be put as by any invariant and objectively measurable quality. Pending further research, we offer a simple way of deciding how to appraise the quality of medical education research.