Translating learning principles into practice: a new strategy for learning clinical skills

Understanding Feedback for Learners in Interprofessional Settings: A Scoping Review

BACKGROUND

Interprofessional feedback is becoming increasingly emphasized within health professions' training programs. The objective of this scoping review is to determine what is known about how learners perceive and interact with feedback in an interprofessional context for learning.

METHODS

A search strategy was developed and conducted in Ovid MEDLINE. Title and abstract screening were performed by two reviewers independently. Next, full texts of selected articles were reviewed by one reviewer to determine the articles included in the review. Data extraction was performed to determine the articles' study population, methodologies and outcomes relevant to the research objective.

RESULTS

Our analysis of the relevant outcomes yielded four key concepts: (1) issues with the feedback process and the need for training; (2) the perception of feedback providers, affecting how the feedback is utilized; (3) professions of the feedback providers, affecting the feedback process; and (4) learners' own attitude toward feedback, affecting the feedback process.

CONCLUSIONS

The learner's perception of interprofessional feedback can be an obstacle in the feedback process. Training around interprofessional feedback should be included as part of interprofessional programs. Research is needed to explore how to address barriers in feedback interaction that stem from misguided perceptions of feedback providers' professions.

More than a feeling? What does compassion in healthcare 'look like' to patients?

OBJECTIVE

Compassion is important to patients and their families, predicts positive patient and practitioner outcomes, and is a professional requirement of physicians around the globe. Yet, despite the value placed on compassion, the empirical study of compassion remains in its infancy and little is known regarding what compassion 'looks like' to patients. The current study addresses limitations in prior work by asking patients what physicians do that helps them feel cared for.

METHODS

Topic modelling analysis was employed to identify empirical commonalities in the text responses of 767 patients describing physician behaviours that led to their feeling cared for.

RESULTS

Descriptively, seven meaningful groupings of physician actions experienced as compassion emerged: listening and paying attention (71% of responses), following-up and running tests (11%), continuity and holistic care (8%), respecting preferences (4%), genuine understanding (2%), body language and empathy (2%) and counselling and advocacy (1%).

CONCLUSION

These findings supplement prior work by identifying concrete actions that are experienced as caring by patients. These early data may provide clinicians with useful information to enhance their ability to customize care, strengthen patient-physician relationships and, ultimately, practice medicine in a way that is experienced as compassionate by patients.

PUBLIC CONTRIBUTION

This study involves the analysis of data provided by a diverse sample of patients from the general community population of New Zealand.

Assessing trainee performance: ensuring learner control, supporting development, and maximizing assessment moments

In this article, the authors provide practical guidance for frontline supervisors' efforts to assess trainee performance. They focus on three areas. First, they argue the importance of promoting learner control in the assessment process, noting that providing learners agency and control can shift the stakes of assessment from high to low and promote a safe environment that facilitates learning. Second, they posit that assessment should be used to support continued development by promoting a relational partnership between trainees and supervisors. This partnership allows supervisors to reinforce desirable aspects of performance, provide real-time support for deficient areas of performance, and sequence learning with the appropriate amount of scaffolding to push trainees from competence (what they can do alone) to capability (what they are able to do with support). Finally, they advocate the importance of optimizing the use of written comments and direct observation while also recognizing that performance is interdependent in efforts to maximize assessment moments.Conclusion: Using best practices in trainee assessment can help trainees take next steps in their development in a learner-centered partnership with clinical supervisors. What is Known: • Many pediatricians are asked to assess the performance of medical students and residents they work with but few have received formal training in assessment. What is New: • This article presents evidence-based best practices for assessing trainees, including giving trainees agency in the assessment process and focusing on helping trainees take next steps in their development.

Online training in evidence-based medicine and research methods for GP registrars: a mixed-methods evaluation of engagement and impact

BACKGROUND

Evidence-based medicine (EBM) is a core skillset for enhancing the quality and safety of patients' care. Online EBM education could improve clinicians' skills in EBM, particularly when it is conducted during vocational training. There are limited studies on the impact of online EBM training on clinical practice among general practitioner (GP) registrars (trainees in specialist general practice). We aimed to describe and evaluate the acceptability, utility, satisfaction and applicability of the GP registrars experience with the online course. The course was developed by content-matter experts with educational designers to encompass effective teaching methods (e.g. it was interactive and used multiple teaching methods).

METHODS

Mixed-method data collection was conducted after individual registrars' completion of the course. The course comprised six modules that aimed to increase knowledge of research methods and application of EBM skills to everyday practice. GP registrars who completed the online course during 2016-2020 were invited to complete an online survey about their experience and satisfaction with the course. Those who completed the course within the six months prior to data collection were invited to participate in semi-structured phone interviews about their experience with the course and the impact of the course on clinical practice. A thematic analysis approach was used to analyse the data from qualitative interviews.

RESULTS

The data showed the registrars were generally positive towards the course and the concept of EBM. They stated that the course improved their confidence, knowledge, and skills and consequently impacted their practice. The students perceived the course increased their understanding of EBM with a Cohen's d of 1.6. Registrars identified factors that influenced the impact of the course. Of those, some were GP-related including their perception of EBM, and being comfortable with what they already learnt; some were work-place related such as time, the influence of supervisors, access to resources; and one was related to patient preferences.

CONCLUSIONS

This study showed that GP registrars who attended the online course reported that it improved their knowledge, confidence, skill and practice of EBM over the period of three months. The study highlights the supervisor's role on GP registrars' ability in translating the EBM skills learnt in to practice and suggests exploring the effect of EBM training for supervisors.

Translation of the shortened dental arch research into clinical practice: a stakeholder mapping approach

AIM

To identify key participants that can ensure implementation of the SDA or PRDA as a prosthodontic management option using a stakeholder mapping approach.

METHODS

A stakeholder mapping approach is employed which is a strategic method to identify, rate the importance of input and the influence, highlighting how clinical implementation can be ensured. A stakeholder map was used as the research tool. Stakeholders were classified according to their level of influence in either assisting with change or obstructing progress as well as the impact of their input within the dental organization and the broader South African environment.

RESULTS

Several stakeholders were identified and were classified in two ways: Primary or secondary and according to their affiliation with the organization where change needs to occur. Initially, a lecture on the shortened dental arch was included in 4th year of undergraduate study, after consultation with the head of the department. This was abandoned as students misunderstood the use of the concept related to clinical requirements; thus, the location of where this concept must be taught, was reconsidered. The role of other key stakeholders that could effect change was also highlighted with this approach.

CONCLUSION

This strategic analysis allowed identification of key stakeholders and their roles that can assist with implementation of the SDA or PRDA, some of whom should be addressed further to ensure alignment of practices to health policies.

KEY POINTS

Knowledge translation consists of multiple stages from design to implementation which includes diffusion, dissemination (such as publishing) and implementation of evidence into clinical practice (application of concepts or procedures to improve patient care).Only quality research, as stipulated on the evidence pyramid, can be used to change curricula and clinical practices.The strategic approach with stakeholder mapping allows identification of key stakeholders in prosthodontics (knowledge brokers or communities of practice) that have the interest and influence to change curricula and clinical practice; including a combined approach with researchers which may enable easier application of quality care to patients.

'Whatever you cut, I can fix it': clinical supervisors' interview accounts of allowing trainee failure while guarding patient safety

BACKGROUND

Learning is in delicate balance with safety, as faculty supervisors try to foster trainee development while safeguarding patients. This balance is particularly challenging if trainees are allowed to experience the educational benefits of failure, acknowledged as a critical resource for developing competence and resilience. While other educational domains allow failure in service of learning, however, we do not know whether or not this strategy applies to clinical training.

METHODS

We conducted individual interviews of clinical supervisors, asking them whether they allowed failure for educational purposes in clinical training and eliciting their experiences of this phenomenon. Participants' accounts were descriptively analysed for recurring themes.

RESULTS

Twelve women and seven men reported 48 specific examples of allowing trainee failure based on their judgement that educational value outweighed patient risk. Various kinds of failures were allowed: both during operations and technical procedures, in medication dosing, communication events, diagnostic procedures and patient management. Most participants perceived minimal consequences for patients, and many described their rescue strategies to prevent an allowed failure. Allowing failure under supervision was perceived to be important for supporting trainee development.

CONCLUSION

Clinical supervisors allow trainees to fail for educational benefit. In doing so, they attempt to balance patient safety and trainee learning. The educational strategy of allowing failure may appear alarming in the zero-error tolerant culture of healthcare with its commitment to patient safety. However, supervisors perceived this strategy to be invaluable. Viewing failure as inevitable, they wanted trainees to experience it in protected situations and to develop effective technical and emotional responses. More empirical research is required to excavate this tacit supervisory practice and support its appropriate use in workplace learning to ensure both learning and safety.

Education, Training and Continuing Professional Development in Medical Acupuncture – a Contemporary Overview

Most medical and complementary medicine practitioners will have some awareness of the government-driven requirement to set and maintain explicit standards for education and professional development. For many doctors, revalidation has become a concern because they worry that it will raise the requirements for practice and increase bureaucratic documentation in support of the process. For those who have integrated complementary practices into their work within the National Health System, issues of registration and regulation add a further complication. The publication of the Department of Health consultation document on proposals for statutory regulation of herbal medicine and acupuncture in March 2004 raises issues of particular significance for medically qualified practitioners (such as ‘medical acupuncturists’), and other health professionals whose practice includes complementary skills. This paper focuses on the educational implications of these recent developments and offers an informed perspective that includes a reflection on how education and training (as initial training and as continuing professional development) can best meet the needs of acupuncture practitioners in this fast-changing environment.

Simulated Patients Are Predominantly Used to Teach and Evaluate Athletic Training Students' Skills: A 10-Year Follow-Up

Context:

Health care education needs to include methods of teaching and evaluation that are realistic and mimic patient care.

Objective:

To follow up on previous research regarding the methods athletic training educators use to evaluate and teach athletic training students' clinical skills during clinical experiences and in the classroom/laboratory.

Design:

Cross-sectional.

Setting:

Public and private institutions.

Patients or Other Participants:

Program directors of all accredited professional athletic training programs as of November 2015 (N = 372) were asked to participate; a total of 90 participated.

Data Collection and Analysis:

The electronic survey consisted of 6 demographic questions, 6 questions regarding methods used to teach and evaluate clinical skills, and 6 items regarding barriers, educational content areas, and practice settings for real-time patient encounters. The Cronbach α determined internal consistency, α = 0.784. Descriptive statistics were computed for all items. An analysis of variance and independent t tests analyzed differences among institutions/programs with different demographic characteristics with regard to methods, barriers, educational content areas, and settings used for teaching and evaluating skills. The α level was set at .05.

Results:

Simulated patients and real-time evaluations were the most prevalent methods of teaching and evaluating clinical skills in the classroom/laboratory and during clinical experiences, respectively. Students' lack of self-confidence (4.10 ± 0.835) was the most common barrier during clinical experiences. The clinical examination and diagnosis (4.54 ± 0.656) and acute care of injury and illness (4.39 ± 0.775) content areas ranked highest for sufficient opportunities for real-time skill evaluation. One-way analysis of variances revealed no significant differences related to institutional/program demographics regarding opportunities for or barriers to teaching and evaluating skills.

Conclusions:

Ten years after our previous research, athletic training students' skills are still primarily taught and evaluated via simulated patients, with a slight increase in real-time patient encounters. Professional programs should continue using simulations and consider real-time encounters to provide additional patient care experiences.

A multicenter study: how do medical students perceive clinical learning climate?

BACKGROUND

The relationship between students and instructors is of crucial importance for the development of a positive learning climate. Learning climate is a multifaceted concept, and its measurement is a complicated process. The aim of this cross-sectional study was to determine medical students' perceptions about the clinical learning climate and to investigate differences in their perceptions in terms of various variables.

METHODS

Medical students studying at six medical schools in Turkey were recruited for the study. All students who completed clinical rotations, which lasted for 3 or more weeks, were included in the study (n=3,097). Data were collected using the Clinical Learning Climate Scale (CLCS). The CLCS (36 items) includes three subscales: clinical environment, emotion, and motivation. Each item is scored using a 5-point Likert scale (1: strongly disagree to 5: strongly agree).

RESULTS

The response rate for the trainees was 69.67% (n=1,519), and for the interns it was 51.47% (n=917). The mean total CLCS score was 117.20±17.19. The rotation during which the clinical learning climate was perceived most favorably was the Physical Therapy and Rehabilitation rotation (mean score: 137.77). The most negatively perceived rotation was the General Internal Medicine rotation (mean score: 104.31). There were significant differences between mean total scores in terms of trainee/intern characteristics, internal medicine/surgical medicine rotations, and perception of success.

CONCLUSION

The results of this study drew attention to certain aspects of the clinical learning climate in medical schools. Clinical teacher/instructor/supervisor, clinical training programs, students' interactions in clinical settings, self-realization, mood, students' intrinsic motivation, and institutional commitment are important components of the clinical learning climate. For this reason, the aforementioned components should be taken into consideration in studies aiming to improve clinical learning climate.

Ten Tips for Maximizing the Effectiveness of Emergency Medicine Procedure Laboratories

Incorporating simulation-based medical education techniques is paramount to ongoing training of emergency physicians. Effective procedure laboratories give learners hands-on experience in life-saving procedures they may otherwise not have clinical exposure to and also prevent skill decay. Using procedural education, adult learning theory, deliberate practice, and mastery learning strategies, the authors offer 10 tips to educators for designing an effective emergency medicine procedure laboratory.

Clinical exercise physiology students learning with older adults: an innovative simulation-based education programme

In this paper, we report on a series of placements for clinical exercise physiology students in a simulation-based education environment with older, independent adults. The purpose of these placement opportunities was to help prepare students to work confidently and competently with older adults in primary healthcare settings. The effectiveness of these placements was measured through semi-structured interviews with the students, their supervisors and the volunteer patients, and also by analysing the content of the students' written reflection assignments. A combination of directed content analysis, informed by the research objectives and imposed upon the data, and conventional content analysis, in which codes were developed from themes emerging from the data, was adopted. Coding was based on units of meaning. Overall, the placement aims were met. Students reported increased confidence in communicating with older adults and in using the tools of their trade. This innovative simulation-based education experience helped students gain an understanding of their developing professional identities. However, the data show that some students still failed to recognise the value and importance of communication when working with older adults. The older adults reported that they enjoyed interacting with the students and believed that they had helped the students gain a positive impression of the cognitive and physical abilities of older adults. These older adults had also gained insight into the benefits of exercise physiology in terms of their own wellbeing. This paper demonstrates the benefits of engaging community support in developing healthcare workers and provides guidelines for replication of these innovative simulation-based education experiences. The paper is limited to reporting the social and community engagement benefits for older adults and the learning opportunities for the clinical exercise physiology students. Further research is needed to demonstrate the health gains for older adults who participate in such programmes.

[Development of guide to clinical performance and basic clinical skills for medical students]

The aim of this report was to discuss the development and content of a guide on clinical performance and basic clinical skills for medical students. We published the first edition of this guide in 2010 and will publish the second edition in 2016. Initially, we took a survey on important clinical presentations and fundamental clinical and technical skills in 41 medical schools in Korea. Ultimately, we chose 80 core clinical presentations and 56 clinical skills. In the guide to basic clinical skills, we described the physical examination and technical skills according to the preprocedural preparation, procedure, and postprocedural process. In the guide on clinical performance, we reviewed patient encounters-from history taking and the physical examination to patient education. We included communication skills, principles of patient safety, and clinical reasoning schemes into the guides. In total, 43 academic faculty members helped develop the basic clinical skills guide, 75 participated in establishing the clinical performance guide, and 16 advisors from 14 medical specialty societies contributed to the guide. These guides can help medical students approach patients holistically and safely.

Development of the clinical learning evaluation questionnaire for undergraduate clinical education: factor structure, validity, and reliability study

BACKGROUND

Teaching and learning of clinical skills for undergraduate medical students usually takes place during the clinical clerkship. Therefore, it is of vital importance to ensure the effectiveness of the rotations within this clerkship. The aims of this study were to develop an instrument that measures the effectiveness of the clinical learning environment, to determine its factor structure, and to find first evidence for the reliability and validity of the total scale and the different factors.

METHODS

The Clinical Learning Evaluation Questionnaire (CLEQ) is an instrument, consisting of 40 items, which have been developed after consideration of the results of a qualitative study that investigated the important factors influencing clinical learning, both from the perspective of students, as well as teachers. Results of relevant literature that investigated this issue were also incorporated in the CLEQ. This instrument was administered to a sample of students (N = 182) from three medical colleges in Riyadh city, the capital of Saudi Arabia. The factor structure of the CLEQ (Principal component analysis, Oblimin rotation) and reliability of the factor scales (Cronbach's α) were determined. Hypotheses concerning the correlations between the different factors were tested to investigate their convergent and divergent validity.

RESULTS

One hundred and nine questionnaires were returned. The factor analysis yielded six factors: F1 Cases (8 items), F2 Authenticity of clinical experience (8 items), F3 Supervision (8 items), F4 Organization of the doctor-patient encounter (4 items), F5 Motivation to learn (5 items), and F6 Self awareness (4 items). The overall internal consistency (α) of the CLEQ was 0.88, and the reliabilities (Cronbach's α) of the six factors varied from .60 to .86. Hypotheses concerning the correlations between the different factors were partly confirmed, which supported the convergent validity of the factors, but not their divergent validity. Significant differences were found between the scores of the students of the three different schools on the factors Supervision and Organization of patient-doctor encounter.

CONCLUSIONS

The results of this study demonstrated that CLEQ is a multidimensional and reliable instrument. It can be utilized as an evaluation tool for clinical teaching activities, both by educators as well as students. Further research is needed into the validity of the CLEQ.

Developing the master learner: applying learning theory to the learner, the teacher, and the learning environment

As a result of the paradigm shift to a competency-based framework, both self-directed lifelong learning and learner-centeredness have become essential tenets of medical education. In the competency-based framework, learners drive their own educational process, and both learners and teachers share the responsibility for the path and content of learning. This learner-centered emphasis requires each physician to develop and maintain lifelong learning skills, which the authors propose culminate in becoming a "master leaner." To better understand the development of these skills and the attainment of that goal, the authors explore how learning theories inform the development of master learners and how to translate these theories into practical strategies for the learner, the teacher, and the learning environment so as to optimize this development.The authors begin by exploring self-determination theory, which lays the groundwork for understanding the motivation to learn. They next consider the theories of cognitive load and situated cognition, which inform the optimal context and environment for learning. Building from this foundation, the authors consider key educational theories that affect learners' abilities to serve as primary drivers of their learning, including self-directed learning (SDL); the self-assessment skills necessary for SDL; factors affecting self-assessment (self-concept, self-efficacy, illusory superiority, gap filling); and ways to mitigate the inaccuracies of self-assessment (reflection, self-monitoring, external information seeking, and self-directed assessment seeking).For each theory, they suggest practical action steps for the learner, the teacher, and the learning environment in an effort to provide a road map for developing master learners.

Feasibility of self-directed learning in clerkships

BACKGROUND

Self-directed learning has been well described in preclinical settings. However, studies report conflicting results when self-directed initiatives are implemented in clinical clerkships.

AIM

To explore the feasibility of self-directed learning stimulated by clinical encounter-cards (CECs) in clinical clerkships.

METHODS

Two focus groups of year-four and year-five students were interviewed about the usefulness of CECs to their learning in clerkships. The CECs were then introduced in two cohorts of 248 year-four and 250 year-five medical students and evaluated on a nine-point scale with regard to usefulness and feasibility.

RESULTS

The pilot groups reported that the CECs had positive effects in terms of engaging in diagnostic reasoning, reflection on management plans, and professional identity formation. However, the two large cohorts of students rated the usefulness of the CECs on learning in clerkship low (year-four: mean 2.92, SD 1.54; year-five: mean 2.28, SD 1.06) along with preceptor support (year-four: mean 2.68, SD 1.62; year-five: mean 2.59, SD 1.78, p = 0.34).

CONCLUSION

Self-directed CECs can have a positive effect on participation and clinical reasoning but are highly dependent on the context of use. Self-directed learning initiatives that aim to increase participation in communities of practice may not be feasible without major faculty development initiatives.

Bedside Teaching: general and discipline-specific teacher characteristics, criteria for patient selection and difficulties

Objective: With regard to bedside teaching (BST), which has an important function in medical education for practicing history taking and clinical examination, only few studies can be found which define recommendations for its realization. However, difficulties with this teaching method are often reported in evaluations. Hence, the goal of this study is to collect important general requirements for bedside teaching and to identify important aspects of patient selection.

Methods: A newly designed questionnaire with closed and open questions concerning the organisation, the execution and the design of BST as well as patient selection was sent to a total of 134 teachers from the departments of surgery, internal medicine and psychiatry. The collected data were analysed using quantitative and qualitative methods.

Results: Teachers from internal medicine were significantly older than teachers from both other disciplines. In surgery, a significantly higher number of hours was taught by younger residents. Patient consent and the match of their diseases to the learning objectives were stated to be the most important factors for patient selection across disciplines. Psychiatrists put significantly more emphasis on patients’ German language skills according to their own declaration. By trend, an acute deterioration of the state of health was mentioned more often in surgery to lead to an exclusion from BST.

Conclusion: With regard to planning of content, organisation and patient selection for BST, aspects mentioned by teachers as well as discipline specific characteristics should be considered for and addressed during teacher trainings.

MiPLAN: a learner-centered model for bedside teaching in today's academic medical centers

Clinician educators and medical trainees face intense pressure to complete numerous patient care and teaching activities in a limited amount of time. To address the need for effective and efficient teaching methods for use in the inpatient setting, the authors used constructivist learning theory, the principles of adult learning, and their expertise as clinician educators to develop the MiPLAN model for bedside teaching. This three-part model is designed to enable clinical teachers to simultaneously provide care to patients while assessing learners, determining high-yield teaching topics, and providing feedback to learners.The "M" refers to a preparatory meeting between teacher and learners before engaging in patient care or educational activities. During this meeting, team members should become acquainted and the teacher should set goals and clarify expectations. The "i" refers to five behaviors for the teacher to adopt during learners' bedside presentations: introduction, in the moment, inspection, interruptions, and independent thought. "PLAN" is an algorithm to establish priorities for teaching subsequent to a learner's presentation: patient care, learners' questions, attending's agenda, and next steps.The authors suggest that the MiPLAN model can help clinical teachers gain more confidence in their ability to teach at the bedside and increase the frequency and quality of bedside teaching. They propose further research to assess the generalizability of this model to other institutions, settings, and specialties and to evaluate educational and patient outcomes.

Clarifying students' feedback-seeking behaviour in clinical clerkships

CONTEXT

Why and how do students seek feedback on their performance in the clinical workplace and which factors influence this? These questions have remained largely unanswered in research into workplace learning during clinical clerkships. Research on feedback has focused mainly on feedback providers. Whether and how feedback recipients actively seek feedback are under-examined issues. Research in organisational psychology has proposed a mechanism whereby feedback seeking is influenced by motives and goal orientation mediated by the perceived costs and benefits of feedback. Building on a recently published model of resident doctors' feedback-seeking behaviour, we conducted a qualitative study to explore students' feedback-seeking behaviours in the clinical workplace.

METHODS

Between April and June 2011, we conducted semi-structured face-to-face interviews with veterinary medicine students in Years 5 and 6 about their feedback-seeking behaviour during clinical clerkships. In the interviews, 14 students were asked about their goals and motives for seeking feedback, the characteristics of their feedback-seeking behaviour and factors influencing that behaviour. Using template analysis, we coded the interview transcripts and iteratively reduced and displayed the data until agreement on the final template was reached.

RESULTS

The students described personal and interpersonal factors to explain their reasons for seeking feedback. The factors related to intentions and the characteristics of the feedback provider, and the relationship between the feedback seeker and provider. Motives relating to image and ego, particularly when students thought that feedback might have a positive effect on image and ego, influenced feedback-seeking behaviour and could induce specific behaviours related to students' orientation towards particular sources of feedback, their orientation towards particular topics for and timing of feedback, and the frequency and method of feedback-seeking behaviour.

CONCLUSIONS

This study shows that during clinical clerkships, students actively seek feedback according to personal and interpersonal factors. Perceived costs and benefits influenced this active feedback-seeking behaviour. These results may contribute towards the optimising and developing of meaningful educational opportunities during clerkships.

Preparing to care for an aging population: medical student reflections on their clinical mentors within a new geriatrics curriculum

Reflective writing techniques such as journaling help provide insights into the process by which medical students are mentored and develop into practicing physicians. The authors sought to analyze medical students' journals regarding their mentored experiences within a new geriatrics curriculum at a U.S. medical school. Thirty preclinical and clinical medical student journalers participated in this project. The authors employed qualitative analytic techniques using an interdisciplinary team process. Three major themes emerged: (a) exposure to clinical mentors challenged medical students' preconceptions regarding older adults and geriatric medicine; (b) students learned new medical knowledge and techniques from observing their mentors; and (c) students provided positive and negative assessments of their mentors. Reflective journaling provides important insights into the process by which medical students draw upon mentored clinical experiences during their training. Such mentorship may be particularly relevant to promoting their interest in geriatrics.

Modernization of an anatomy class: From conceptualization to implementation. A case for integrated multimodal-multidisciplinary teaching

It has become increasingly apparent that no single method for teaching anatomy is able to provide supremacy over another. In an effort to consolidate and enhance learning, a modernized anatomy curriculum was devised by attempting to take advantage of and maximize the benefits from different teaching methods. Both the more traditional approaches to anatomy teaching, as well as modern, innovative educational programs were embraced in a multimodal system implemented over a decade. In this effort, traditional teaching with lectures and dissection was supplemented with models, imaging, computer-assisted learning, problem-based learning through clinical cases, surface anatomy, clinical correlation lectures, peer teaching and team-based learning. Here, we review current thinking in medical education and present our transition from a passive, didactic, highly detailed anatomy course of the past, to a more interactive, as well as functionally and clinically relevant anatomy curriculum over the course of a decade.

The role of deliberate practice in the acquisition of clinical skills

BACKGROUND

The role of deliberate practice in medical students' development from novice to expert was examined for preclinical skill training.

METHODS

Students in years 1-3 completed 34 Likert type items, adapted from a questionnaire about the use of deliberate practice in cognitive learning. Exploratory factor analysis and reliability analysis were used to validate the questionnaire. Analysis of variance examined differences between years and regression analysis the relationship between deliberate practice and skill test results.

RESULTS

875 students participated (90%). Factor analysis yielded four factors: planning, concentration/dedication, repetition/revision, study style/self reflection. Student scores on 'Planning' increased over time, score on sub-scale 'repetition/revision' decreased. Student results on the clinical skill test correlated positively with scores on subscales 'planning' and 'concentration/dedication' in years 1 and 3, and with scores on subscale 'repetition/revision' in year 1.

CONCLUSIONS

The positive effects on test results suggest that the role of deliberate practice in medical education merits further study. The cross-sectional design is a limitation, the large representative sample a strength of the study. The vanishing effect of repetition/revision may be attributable to inadequate feedback. Deliberate practice advocates sustained practice to address weaknesses, identified by (self-)assessment and stimulated by feedback. Further studies should use a longitudinal prospective design and extend the scope to expertise development during residency and beyond.

Students' and general practitioners' perceptions of a recently introduced clerkship in general practice. A survey from Austria

BACKGROUND

In autumn 2007, the Medical University of Graz (MUG) upgraded the status of general practice in medical training by integrating a compulsory five-week clerkship in general practice surgeries in the sixth and last year of the curriculum. In cooperation with the Styrian Academy of General Practice (STAFAM), more than 200 general practitioners (GPs) had been accredited to introduce medical students to the specific tasks, problems and decision-making process in general practice. Between October 2007 and June 2009, more than 300 students completed the clerkship.

OBJECTIVE

To explore the perceptions of students and GPs towards this new approach to undergraduate teaching in Austrian general practice.

METHODS

Between March and June 2009, we conducted a cross-sectional survey by using a self-administered questionnaire with 14 items for students as well as GPs. To limit recall bias, we gave the questionnaire to all students (n = 146) and GPs (n = 146) immediately after the clerkship. The response rates were 146/146 (100%) and 114/146 (78%) for students and GPs, respectively.

RESULTS

The study results show high satisfaction rates among students as well as GPs. Most of the students and GPs perceive the compulsory clerkship in general practice as an essential part of medical education. The organization of the clerkship had the least positive outcome.

CONCLUSION

Our survey shows that the clerkship is well accepted among Austrian medical students and GPs.

Integrated case learning: teaching clinical reasoning

Learning how to 'think like doctors' can be difficult for undergraduate medical students in their early clinical years. Our model of collaborative Integrated Case Learning (ICL) and simulated clinical reasoning aims to address these issues. Taking a socio-cultural perspective, this study investigates the reflective learning interactions and practices of clinical thinking that emerged in the ICL environment. We also explore how third year medical students perceived their ICL experiences in relation to the clinical situations encountered in the hospital setting. The context for the inquiry is a rural Clinical School in North West Victoria, Australia. We used a qualitative case study methodology following eight third-year medical students over an academic year. Individual and group interviews were conducted, together with observations and document/artefact analysis. Data was analysed using content and narrative methods. The ICL program was well received. Findings suggest that the group-based, simulated clinical reasoning process appears to help undergraduate medical students to rehearse, articulate and question their clinical decision-making pathways. We argue that the ICL process offers a professionally challenging, but supportive group learning 'space' for students to practise what it might mean to 'think', 'talk' and 'perform' like doctors in real settings. The ICL environment also appears to create a connective bridge between the 'classroom' and clinical practice.

The utility of simulation in medical education: what is the evidence?

Medical schools and residencies are currently facing a shift in their teaching paradigm. The increasing amount of medical information and research makes it difficult for medical education to stay current in its curriculum. As patients become increasingly concerned that students and residents are "practicing" on them, clinical medicine is becoming focused more on patient safety and quality than on bedside teaching and education. Educators have faced these challenges by restructuring curricula, developing small-group sessions, and increasing self-directed learning and independent research. Nevertheless, a disconnect still exists between the classroom and the clinical environment. Many students feel that they are inadequately trained in history taking, physical examination, diagnosis, and management. Medical simulation has been proposed as a technique to bridge this educational gap. This article reviews the evidence for the utility of simulation in medical education. We conducted a MEDLINE search of original articles and review articles related to simulation in education with key words such as simulation, mannequin simulator, partial task simulator, graduate medical education, undergraduate medical education, and continuing medical education. Articles, related to undergraduate medical education, graduate medical education, and continuing medical education were used in the review. One hundred thirteen articles were included in this review. Simulation-based training was demonstrated to lead to clinical improvement in 2 areas of simulation research. Residents trained on laparoscopic surgery simulators showed improvement in procedural performance in the operating room. The other study showed that residents trained on simulators were more likely to adhere to the advanced cardiac life support protocol than those who received standard training for cardiac arrest patients. In other areas of medical training, simulation has been demonstrated to lead to improvements in medical knowledge, comfort in procedures, and improvements in performance during retesting in simulated scenarios. Simulation has also been shown to be a reliable tool for assessing learners and for teaching topics such as teamwork and communication. Only a few studies have shown direct improvements in clinical outcomes from the use of simulation for training. Multiple studies have demonstrated the effectiveness of simulation in the teaching of basic science and clinical knowledge, procedural skills, teamwork, and communication as well as assessment at the undergraduate and graduate medical education levels. As simulation becomes increasingly prevalent in medical school and resident education, more studies are needed to see if simulation training improves patient outcomes.

Physiotherapy students' and clinical teachers' perceptions of clinical learning opportunities: a case study

BACKGROUND

The attainment of clinical competence is a key outcome of physiotherapy programmes worldwide. Clinical education forms a core component of the training of physiotherapy students.

AIMS

The study on which this article is based aimed to investigate what physiotherapy students and clinical teachers at one physiotherapy training institution perceive as effective opportunities to facilitate learning in a clinical context.

METHODS

A survey of staff and students at the physiotherapy division at Stellenbosch University was undertaken as one element of a situational case study. All enrolled physiotherapy students with clinical education experience and all clinical teachers involved in the clinical education of these students were invited to participate. A purpose-built questionnaire was developed and validated before being administered.

RESULTS

The response rate was 80%. The clinical teaching and learning opportunities deemed most valuable for learning by students and teachers were demonstrations of patient management, feedback, discussions and assessment. Teachers and students varied in their perceptions of the learning value of peer assessment, self-assessment and reflection.

CONCLUSIONS

The study provided indications for teachers on the valuable learning opportunities as perceived by students and teachers in a physiotherapy clinical setting. The activities perceived as most effective in facilitating learning in the clinical milieu were demonstrations of patient management, discussion, feedback and assessment. Participants indicated that they valued individual contact with teachers and that they learnt productively from discussions with the teachers. It was reported that immediate and verbal feedback improved the learning experience. Both formative assessment in the form of a mock assessment and summative assessment in the form of an end-of-block test were identified as important in facilitating learning. Further research is required on peer assessment, self-assessment and reflection to establish the role of these aspects of learning.

What is feedback in clinical education?

OBJECTIVE

Feedback is important in clinical education. However, the medical education literature provides no consensual definition of feedback. The aim of this study is to propose a consensual, research-based, operational definition of feedback in clinical education. An operational definition is needed for educational practice and teacher training, and for research into the effectiveness of different types of feedback.

METHODS

A literature search about definitions of feedback was performed in general sources, meta-analyses and literature reviews in the social sciences and other fields. Feedback definitions given from 1995 to 2006 in the medical education literature are also reviewed.

RESULTS

Three underlying concepts were found, defining feedback as 'information'; as 'reaction', including information, and as a 'cycle', including both information and reaction. In most medical education and social science literature, feedback is usually conceptualised as information only. Comparison of feedback definitions in medical education reveals at least 9 different features. The following operational definition is proposed. Feedback is: 'Specific information about the comparison between a trainee's observed performance and a standard, given with the intent to improve the trainee's performance.'

CONCLUSIONS

Different conceptual representations and the use of different key features might be a cause for inconsistent definitions of feedback. The characteristics, strengths and weaknesses of this research-based operational definition are discussed.

Early student-patient contacts in general practice: an approach based on educational principles

BACKGROUND

Clinical teaching and learning is generally seen as an educationally sound approach, but the clinical environment does not always offer optimal conditions to facilitate students' learning processes.

AIMS

To show how insights on constructing a good learning environment for student-patient contacts in real practice can be translated into an undergraduate clinical general practice programme in Year 3 and to study its feasibility.

METHOD

Literature search, yielding starting points for the development of the new programme and questionnaire evaluation of the programme.

RESULTS

Six starting points for a good learning environment for early student-patient contacts: continuing exposure to patients,transformation of experience into knowledge, active role of students, supervision and feedback, time and space for teaching and teacher training were translated into a the new programme. The evaluation showed that the programme was feasible and well received by students and GPs, although some improvements are possible.

CONCLUSION

In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in general practice based on educational principles.

Challenges substance abuse treatment agencies faced in adoption of computer-based technology to improve assessment

The Oregon Practice Improvement Collaborative provided resources and technical assistance to help five Oregon drug treatment agencies adopt computer-based technology of their choice to support client progress in treatment. This manuscript describes agency processes related to that adoption of technology. Agencies chose computer programs to improve clinical outcomes, reduce staff burden, and respond to external pressures. Agencies used a combination of top-down and bottom-up approaches to involve staff in decision making. Agencies guided staff from current practice to a standardized paper-and-pencil tool, then from the paper-and-pencil tool to its electronic version. Staff experienced barriers in technology-related training, logistical challenges in integrating the technology, and sustaining the technology.

Undergraduate teaching of child and adolescent psychiatry in Australia: survey of current practice

OBJECTIVE

To identify the goals, content, and time allocated for undergraduate child psychiatry teaching programmes in Australian medical schools.

METHOD

A structured questionnaire designed specifically for the present study was used to identify the goals, content, and time allocated to child psychiatry teaching for undergraduate medical students. Staff responsible for child psychiatry teaching programmes at all 15 medical schools in Australia were contacted and those in 12 schools (80%) agreed to participate.

RESULTS

All 12 medical schools provided some teaching relevant to child psychiatry. Teaching was commonly provided as part of general psychiatry and/or paediatric teaching programmes. Between 4 and 12 h were allocated for child psychiatry teaching, with the exception of one school, which assigned 46 h. Ten schools (83%) offered clinical placements in child psychiatry to some or all students, with placements ranging in length from 0.5 days to 8 weeks. However, only four schools (33%) offered clinical placements to all students. Two schools (17%) offered no clinical placements or electives in child psychiatry. The skills required to assess children and families, and knowledge about normal child development were identified as key teaching goals. Barriers to teaching child psychiatry included the lack of academic child psychiatrists in Australia, and the limited time allocated for this teaching in medical school curricula.

CONCLUSIONS

The amount of time allocated for teaching child psychiatry in Australian medical schools is relatively small and not consistent with the size of the public health problem posed by child and adolescent mental disorders. Staff responsible for teaching child psychiatry need to coordinate their activities more effectively at a national level to identify teaching goals, design curricula, and advocate for high-quality child psychiatry teaching programmes in medical schools.

Early introduction of clinical skills improves medical student comfort at the start of third-year clerkships

BACKGROUND

To determine whether introducing clinical skills during the second year of medical school, via a competency-based College system approach, improves comfort level for medical students entering third-year clinical rotations.

METHOD

From 2003-2005, two cohorts of third-year medical students at the University of Washington were surveyed on their comfort level in the categories of history taking, physical examination, communication, and patient care.

RESULTS

The cohort of students exposed to the College system reported a statistically significant greater comfort level in half of the measured areas, and in at least one area within each general category. No area of study showed a statistically significant decline.

CONCLUSION

A competency-based College system improves medical student comfort in core clinical skills at the start of the third year curriculum.

Teaching in practice: a survey of a general practice teaching network

The need for high-quality teaching practices and general practitioners (GPs) skilled in teaching is ever increasing. The authors determined the quality of teaching in the Göttingen general practice teaching network with regard to equipment, student participation and GPs' motivation for teaching. A questionnaire was mailed to all GPs in the Göttingen teaching network. The response rate was 81% (98/121). GPs considered taking histories (98%), decision-making (98%) and physical examination (94%) to be key elements of teaching in general practice. They felt that somatic topics like upper respiratory tract infections (98%) were easy to teach, while 51% acknowledged difficulties conveying psychosocial topics like caring for dying patients. In only half of the practices did students have the opportunity to take histories and perform physical exams by themselves. Participation in medical education was driven mainly by the satisfaction derived from teaching (66%) and the desire for academic affiliation (39%). GPs in the Göttingen network need support to teach their students more psychosocial-oriented topics and to allow them a more active role in consultations.

Brief report: Use of the mini-clinical evaluation exercise in internal medicine core clerkships

INTRODUCTION

Direct observation of medical students' clinical skills is important, but occurs infrequently. The mini-clinical evaluation exercise (mCEX) is a tool developed for use with internal medicine (IM) residents that can be used to promote direct observation of medical students' clinical skills. It is unknown how many IM core clerkships in the United States use the mCEX or how it has been implemented.

METHODS

Questions about use of the mCEX were incorporated into an online annual survey distributed to the 114 IM clerkships belonging to Clerkship Directors in Internal Medicine, a national organization of individuals responsible for teaching IM to medical students.

RESULTS

The survey response rate was 83%. Twenty-eight percent (N=27) of respondents use the mCEX in their clerkship. The mean number of required mCEX encounters is 2.3 (SD 1.6). The mCEX is used for formative assessment (68%) more than summative assessment (11%). Ward attendings are the most common mCEX evaluators (72%).

DISCUSSION

The mCEX is being used to promote direct observation of medical students' clinical skills in a significant minority of IM core clerkships. The mCEX is 1 tool for facilitating feedback from both faculty and residents on trainees' developing skills.

The use of simulated learning to promote safe blood transfusion practice

The transfusion of blood and blood products is a complex, multi-professional task which is liable to errors at any point in the journey from donor to recipient. The serious hazards of transfusion (SHOT) scheme has documented reports which consistently demonstrate that the administration of the incorrect blood component is a major cause of morbidity and mortality in the United Kingdom. Training programmes which focus on different stages of safe effective blood transfusion are currently available but none involve practice in the workplace setting. This paper shares the design, implementation and subsequent evaluation of a simulated ward exercise, which was developed in partnership with the Scottish National Blood Transfusion Service (SNBTS), NHS Tayside and the University of Dundee Medical School to reinforce learning in a workplace context. The exercise was evaluated from a number of different perspectives. The exercise demonstrated that it is an effective method of reinforcing safe transfusion practice in a non-threatening realistic workplace environment. Costs in terms of time, finance and staff numbers may however preclude large scale implementation in practice.

Basic life support skills training in a first year medical curriculum: six years' experience with two cognitive-constructivist designs

RATIONALE

Although the Basic Life Support (BLS) ability of a medical student is a crucial competence, poor BLS training programs have been documented worldwide. Better training designs are needed. This study aims to share detailed descriptions and the test results of two cognitive-constructivist training models for the BLS skills in the first year of medical curriculum.

METHOD

A BLS skills training module was implemented in the first year curriculum in the course of 6 years (1997-2003). The content was derived from the European Resuscitation Council Guidelines. Initially, a competence-based model was used and was upgraded to a cognitive apprenticeship model in 2000. The main performance-content type that was expected at the end of the course was: competent application of BLS procedures on manikins and peers at an OSCE as well as 60% achievement in a test consisting of 25 MCQ items. A retrospective cohort survey design using exam results and a self-completed anonymous student ratings' questionnaire were used in order to test models.

RESULTS

Training time for individual students varied from 21 to 29 hours. One thousand seven hundred and sixty students were trained. Fail rates were very low (1.0-2.2%). The students were highly satisfied with the module during the 6 years.

CONCLUSION

In the first year of the medical curriculum, a competence-based or cognitive apprenticeship model using cognitive-constructivist designs of skills training with 9 hours theoretical and 12-20 hours long practical sessions took place in groups of 12-17 students; medical students reached a degree of competence to sufficiently perform BLS skills on the manikins and their peers. The cognitive-constructivist designs for skills training are associated with high student satisfaction. However, the lack of controls limits the extrapolation of this conclusion.

Broadening conceptions of learning in medical education: the message from teamworking

BACKGROUND

There is a mismatch between the broad range of learning theories offered in the wider education literature and a relatively narrow range of theories privileged in the medical education literature. The latter are usually described under the heading of 'adult learning theory'.

METHODS

This paper critically addresses the limitations of the current dominant learning theories informing medical education. An argument is made that such theories, which address how an individual learns, fail to explain how learning occurs in dynamic, complex and unstable systems such as fluid clinical teams.

RESULTS

Models of learning that take into account distributed knowing, learning through time as well as space, and the complexity of a learning environment including relationships between persons and artefacts, are more powerful in explaining and predicting how learning occurs in clinical teams. Learning theories may be privileged for ideological reasons, such as medicine's concern with autonomy.

CONCLUSIONS

Where an increasing amount of medical education occurs in workplace contexts, sociocultural learning theories offer a best-fit exploration and explanation of such learning. We need to continue to develop testable models of learning that inform safe work practice. One type of learning theory will not inform all practice contexts and we need to think about a range of fit-for-purpose theories that are testable in practice. Exciting current developments include dynamicist models of learning drawing on complexity theory.

Breaking bad news: qualitative evaluation of an interprofessional learning opportunity

This paper analyses the effects of bringing together a small group of nursing and medical students to learn the skills needed to break bad news to patients. It outlines the qualitative and quantitative methods used, to provide the reader with a comprehensive account of the teaching, learning and research strategies drawn on during the study. The paper examines the evaluation phase, as this aspect is of greatest import if such initiatives are to flourish. The facet of the study analysed in detail concerns the students' responses to the open-ended qualitative questionnaires. In coding the data, three researchers independently highlighted a series of themes associated with the benefits and hazards of nursing and medical students learning and working together. Finally, the paper closes by arguing that trust and mutual respect are vital ingredients if collaborative working is to become part of the medical and nursing curriculum.

Appropriateness of use of medicines in elderly inpatients: qualitative study

OBJECTIVES

To explore the processes leading to inappropriate use of medicines for elderly patients admitted for acute care.

DESIGN

Qualitative study with semistructured interviews with doctors, nurses, and pharmacists; focus groups with inpatients; and observation on the ward by clinical pharmacists for one month.

SETTING

Five acute wards for care of the elderly in Belgium.

PARTICIPANTS

5 doctors, 4 nurses, and 3 pharmacists from five acute wards for the interviews; all professionals and patients on two acute wards for the observation and 17 patients (from the same two wards) for the focus groups.

RESULTS

Several factors contributed to inappropriate prescribing, counselling, and transfer of information on medicines to primary care. Firstly, review of treatment was driven by acute considerations, the transfer of information on medicines from primary to secondary care was limited, and prescribing was often not tailored to elderly patients. Secondly, some doctors had a passive attitude towards learning: they thought it would take too long to find the information they needed about medicines and lacked self directed learning. Finally, a paternalistic doctor-patient relationship and difficulties in sharing decisions about treatment between prescribers led to inappropriate use of medicines. Several factors, such as the input of geriatricians and good communication between members of the multidisciplinary geriatric team, led to better use of medicines.

CONCLUSIONS

In this setting, improvements targeted at the abilities of individuals, better doctor-patient and doctor-doctor relationships, and systems for transferring information between care settings will increase the appropriate use of medicines in elderly people.

Promoting fundamental clinical skills: a competency-based college approach at the University of Washington

The focus on fundamental clinical skills in undergraduate medical education has declined over the last several decades. Dramatic growth in the number of faculty involved in teaching and increasing clinical and research commitments have contributed to depersonalization and declining individual attention to students. In contrast to the close teaching and mentoring relationship between faculty and students 50 years ago, today's medical students may interact with hundreds of faculty members without the benefit of a focused program of teaching and evaluating clinical skills to form the core of their four-year curriculum. Bedside teaching has also declined, which may negatively affect clinical skills development. In response to these and other concerns, the University of Washington School of Medicine has created an integrated developmental curriculum that emphasizes bedside teaching and role modeling, focuses on enhancing fundamental clinical skills and professionalism, and implements these goals via a new administrative structure, the College system, which consists of a core of clinical teachers who spend substantial time teaching and mentoring medical students. Each medical student is assigned a faculty mentor within a College for the duration of his or her medical school career. Mentors continuously teach and reflect with students on clinical skills development and professionalism and, during the second year, work intensively with them at the bedside. They also provide an ongoing personal faculty contact. Competency domains and benchmarks define skill areas in which deepening, progressive attention is focused throughout medical school. This educational model places primary focus on the student.

The impact of multifaceted educational structuring on learning effectiveness in a surgical clerkship

INTRODUCTION

Various measures have been introduced to enhance learning experiences in clerkships, generally with limited success. This study evaluated the impact of a multifaceted approach on the effectiveness of learning in a surgical clerkship. In accordance with results obtained in continuing medical education, several interventions were introduced simultaneously. We compared students' evaluations of the traditional surgical clerkship with those of the restructured clerkship.

METHODS

Two consecutive cohorts of students were asked to complete a questionnaire about the quality and quantity of their learning experiences. Cohort 1 (n = 28) undertook the traditional clerkship and cohort 2 (n = 72) the restructured clerkship. A Mann-Whitney test was used to compare outcomes between the 2 cohorts.

RESULTS

There were few statistically significant differences between cohorts 1 and 2. Overall, quality indicators did not differ between the 2 cohorts.

DISCUSSION

A short-term multifaceted intervention led to a slight increase in the performance of clinical skills and a slight decrease in time spent on activities of limited educational value. The intervention may have been too brief to produce substantial effects. Future interventions should also target teachers, including trainees, in order to assess their opinions and address their educational needs.

Learning from the problems of problem-based learning

BACKGROUND

The last decade has witnessed a rapid expansion of biomedical knowledge. Despite this, fashions in medical education over the same period have shifted away from factual (didactic) teaching and towards contextual, or problem-based, learning (PBL). This paradigm shift has been justified by studies showing that PBL improves reasoning and communication while being associated with few if any detectable knowledge deficits.

DISCUSSION

Analysis of the literature indicates that the recent rapid rise of PBL has closely paralleled the timing of the information explosion. The growing dominance of PBL could thus worsen the problems of information management in medical education via several mechanisms: first, by creating the impression that a defined spectrum of core factual knowledge suffices for clinical competence despite ongoing knowledge expansion (quality cost); second, by dissuading teachers from refining the educational utility of didactic modalities (improvement cost); and third, by reducing faculty time for developing reusable resources to impart factual knowledge more efficiently (opportunity cost).

SUMMARY

These costs of PBL imply a need for strengthening the knowledge base of 21st-century medical graduates. New initiatives towards this end could include the development of more integrated cognitive techniques for facilitating the comprehension of complex data; the design of differentiated medical curricula for producing graduates with defined high-priority skill sets; and the encouragement of more cost-effective faculty teaching activities focused on the prototyping and testing of innovative commercializable educational tools.