Effect of a community oriented problem based learning curriculum on quality of primary care delivered by graduates: historical cohort comparison study

A Multicenter Evaluation of a Metacognitive Framework for Antimicrobial Selection Education

Antimicrobial selection is a complex task for veterinary students there is a need for both assessment tools and novel strategies to promote the proper use of antimicrobials. SODAPOP (Source-Organism-Decided to treat-Antimicrobials-Patient- Option-Plan) is a mnemonic previously designed to aid in developing antimicrobial selection skills by promoting metacognition. To assess the effect of this tool, we enrolled veterinary students (N = 238) from five veterinary teaching institutions in a study that consisted of an online survey that contained a video-based intervention. For the intervention, a video that presented principles of antimicrobial selection was embedded within the survey. For one-half of students, the video also included an explanation of SODAPOP. The survey included self-efficacy statements rated by participants pre-intervention and post-intervention. The survey also included cases, developed for this study, that were used to assess selection and plan competence. Cases were graded using two study-developed rubrics in a blinded fashion by veterinary educators. A statistically significant difference was found in participant-reported self-efficacy pre-scores and post-scores when asked about empiric prescribing (5.8 vs. 6.5; P = .0153) for the SODAPOP group but not the control group. No immediate impact on competence was found. When asked whether SODAPOP was an essential educational tool and likely to be used by participants in the future, the mean rank score (from 1-10) was 7.6 and 7.2, respectively. In addition to developing cases and rubrics, this study demonstrated that SODAPOP may be a useful tool for integration into approaches for teaching antimicrobial selection to veterinary students.

Implementation of Problem-Based Learning in Undergraduate Medical Education in Ethiopia: An Exploratory Qualitative Study

Background

The poor quality of health professional education in Ethiopia, which was rooted in a traditional curriculum, has posed significant challenges for graduates in effectively addressing real-life health problems. In response, there has been curricular reform by adopting problem-based learning across Ethiopian medical schools. Given the dearth of literature on the topic and the significance of context in the effective implementation of problem-based learning, it is imperative to provide local institutional evidence to pinpoint critical intervention areas and support the effective implementation of problem-based learning.

Methods

A qualitative design based on in-depth, individual, semi-structured interviews was used to explore medical educators, program coordinators, and educational leader's experiences and perspectives on the problem-based learning implementation in health sciences education. A total of 24 participants recruited from five undergraduate health science programs participated in the study. All sessions were audio recorded and transcribed verbatim. Results were analyzed following a qualitative thematic analysis method.

Results

Analysis of the transcripts revealed three main themes, along with their corresponding subthemes. Within the first main theme, participants discussed the importance of integrating Problem-Based Learning into undergraduate medical programs and the educational benefits it brings to medical education. The second main theme explored issues related to challenges in implementing problem-based learning which include inadequate staff training, deficiencies in curricular design and governance, constraints in educational resources, and a lack of preparedness in the educational environment. The third theme deals with the strategic recommendations to address the challenges that contributed to the poor implementation of problem-based learning in undergraduate medical schools.

Conclusion

Our study has addressed several issues related to the implementation of Problem-Based Learning in Ethiopian Health Sciences Colleges. The study's findings have the potential to provide educational stakeholders and policymakers with essential information to strategize successful problem-based learning implementation in undergraduate medical schools.

The Role of Problem-Based Learning in Preparing Medical Students to Work As Community Service-Oriented Primary Care Physicians: A Systematic Literature Review

The number of primary care physicians in the United States is dwindling rapidly, and osteopathic medical schools are embracing the challenge of leading students toward a career in primary care to meet this need. In recent years, the Problem-Based Learning (PBL) curriculum in medical education has emerged as a patient-centered, social-justice-focused methodology. The unique format of PBL centered around patient cases allows learning through community-based medicine, promoting medical graduates' entry into primary care. Through exploring the literature on this topic, the research question posed for this review is as follows: How have the skills gained in PBL been effectively preparing medical students to become community service-oriented primary care physicians, and how can we qualitatively and quantitatively assess a learner's preparedness to engage in primary care work? The variables studied were board licensing examination scores, clinical competence, and interpersonal skills, all of which emerged as common ways to assess learners' preparedness to work in primary care. The methodology of this literature review was organized using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart to describe how articles were selected and synthesized to evaluate the variables. The results revealed the variables to be consistent strengths of PBL students, particularly clinical competence, and interpersonal skills, both of which are key in working in primary care and any clinical specialty. Since early in its implementation, literature has demonstrated the tendencies of PBL students to be interested in and later work in primary care, though little follow-up has been done recently. The question of why this phenomenon exists was largely answered by our literature review. In conclusion, through our analysis of the existing literature, the authors demonstrated that the PBL curriculum helps foster students' desire to serve patients. Limitations of the literature included small sample sizes, heterogeneous analysis methods, limited inclusion of qualitative assessment of student progress, and limited existing data on the prevalence of PBL in medical schools, as well as the entrance of PBL graduates into primary care careers.

Effectiveness of problem-based learning methodology in undergraduate medical education: a scoping review

BACKGROUND

Problem-based learning (PBL) is a pedagogical approach that shifts the role of the teacher to the student (student-centered) and is based on self-directed learning. Although PBL has been adopted in undergraduate and postgraduate medical education, the effectiveness of the method is still under discussion. The author's purpose was to appraise available international evidence concerning to the effectiveness and usefulness of PBL methodology in undergraduate medical teaching programs.

METHODS

The authors applied the Arksey and O'Malley framework to undertake a scoping review. The search was carried out in February 2021 in PubMed and Web of Science including all publications in English and Spanish with no limits on publication date, study design or country of origin.

RESULTS

The literature search identified one hundred and twenty-four publications eligible for this review. Despite the fact that this review included many studies, their design was heterogeneous and only a few provided a high scientific evidence methodology (randomized design and/or systematic reviews with meta-analysis). Furthermore, most were single-center experiences with small sample size and there were no large multi-center studies. PBL methodology obtained a high level of satisfaction, especially among students. It was more effective than other more traditional (or lecture-based methods) at improving social and communication skills, problem-solving and self-learning skills. Knowledge retention and academic performance weren't worse (and in many studies were better) than with traditional methods. PBL was not universally widespread, probably because requires greater human resources and continuous training for its implementation.

CONCLUSION

PBL is an effective and satisfactory methodology for medical education. It is likely that through PBL medical students will not only acquire knowledge but also other competencies that are needed in medical professionalism.

The Effect of the Educational Environment on the rate of Burnout among Postgraduate Medical Trainees - A Narrative Literature Review

BACKGROUND

Burnout among postgraduate medical trainees is common. It is a syndrome characterised by emotional exhaustion, depersonalisation and reduced personal accomplishment. Burnout is seen as an organisational problem rather than the result of an individual's ability to cope with the stress at work. The educational environment can play a pivotal role in the prevention of burnout among postgraduate medical trainees. This narrative literature review is aimed at assessing the effect of the educational environment on burnout in postgraduate doctors-in-training.

METHODS

A search of the databases Medline and PscyInfo for articles published between 2015 and 2020 was performed with the key words 'burnout' and 'educational environment' or 'clinical learning environment' or 'postgraduate medical education' or 'learning environment'.

RESULTS

A total of 27 studies were identified and reviewed by the author. The prevalence of burnout reported varied widely between studies, ranging from 10% to 62%. Many of the factors that contribute to burnout form part of the educational environment, for example, hours worked, mistreatment, harassment and perceptions of injustice. Residency itself is a stressful period wherein trainees have to balance their responsibilities towards their patients with their responsibilities at home, all while furthering their studies and taking on new responsibilities. Interventions to prevent burnout and tackle existing burnout are multiple but very little solid evidence exists to attest to their efficacy. More research is needed to identify the most effective ways to deal with burnout in postgraduate medical trainees.

An Analysis of the Educational Environment at the Malta Foundation Programme Using the Postgraduate Hospital Educational Environment Measure (PHEEM)

BACKGROUND

Learning from managing patients in a real-world context is by far superior to simulation learning. A substandard educational environment is associated with poor patient care and suboptimal learning outcomes. The measurement of the educational environment provides insight into what is needed to improve the level of training.

OBJECTIVE

To measure the educational environment as perceived by trainees within the Malta Foundation Programme.

METHODS

This study used the Postgraduate Hospital Educational Environment Measure (PHEEM) to measure the educational environment at the Malta Foundation Programme. Descriptive statistics were used to describe the demographics of the study population. Nonparametric comparative statistics were used to identify statistically significant differences between groups.

RESULTS

Ninety-eight trainees out of 370 (26.5%) completed the online questionnaire. These consisted of 39 FY1s (31.5% of 124), 33 FY2s (24.8% of 133), and 26 extended FYs (23.0% of 113). The 40-item PHEEM showed good reliability with a Cronbach's α value of .912. These doctors perceived their educational environment as more positive than negative. Perceptions are worst among trainees at the end of their first year of training. Those who had just finished their training have reported better perceptions. The 3 worst scoring items are related to when the trainees are on call.

CONCLUSION

Among trainees within the Malta Foundation Programme, perceptions of role autonomy and social support are areas where most work is needed. Teaching seems to be moving in the right direction, but there is always room for improvement.

Learning person-centred consultation skills in clinical medicine: A randomised controlled case study

Background: Training institutions need to ensure that healthcare students learn the skills to conduct person-centred consultations. We studied changes in person-centred practice over time following a quality improvement (QI) intervention among Bachelor of Clinical Medical Practice undergraduate students.Methods: Students were randomised to intervention and control groups. The intervention group received training and did a QI cycle on their own consultation skills. Consultations with simulated patients were recorded during structured clinical examinations in June (baseline) and November (post-intervention) 2015.Results: Matched consultations for 64 students were analysed. The total SEGUE (Set the stage, Elicit information, Give information, Understand the patient’s perspective and End the encounter scores) were significantly higher in the final assessment compared to baseline for both the whole group and the intervention group (p = 0.005 and 0.015, respectively). The improvement did not differ significantly between intervention and control groups (p = 0.778). Third-year students improved significantly more than second years (p = 0.007).Conclusion: The person-centred practice (including collaboration) of clinical associate students did improve over the period studied. The results show that students’ learning of person-centred practice also happened in ways other than through the QI intervention. There is a need to develop students’ collaborative skills during the medical consultation.

The clinical learning environment

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinical learning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed "avenues:" architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various "avenues" in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.

Community Preceptors' Motivations and Views about Their Relationships with Medical Students During a Longitudinal Family Medicine Experience: A Qualitative Case Study

Phenomenon: Although current evidence emphasizes various benefits of community-oriented programs, little is still known about the nature of the relationships that students and family physicians develop in this educational setting. Our aim in this study was twofold: to identify family physicians' motivations to enroll as preceptors in a longitudinal undergraduate family medicine program and to explore the nature of the student-preceptor relationships built during the course. Approach: This was a qualitative exploratory case study. The case was the first edition of a longitudinal family medicine experience (LFME), a course that makes up part of the novel Medicinae Doctor et Chirurgiae Magister curriculum in place in a Canadian medical school since August 2013. All 173 family physician community preceptors of the academic year 2013-2014 were considered key informants in the investigation. Forty-three preceptors finally participated in one of six focus groups conducted in the spring of 2014. Several organizational documents relative to the LFME course were also gathered. Inductive semantic thematic analysis was performed on verbatim interview transcripts. Documents helped contextualize the major themes emerging from the focus groups discussions. Findings: Enjoying teaching, promoting family medicine, and improving medical education where salient motivations for family physicians to become LFME preceptors. The findings also pointed out the complexity of the student-preceptor exchanges that unfolded over the academic year, and the ambiguous and changing nature of the role that LFME preceptors adopted in their relationships with students: from simply being facilitators of students' clinical observership to behaving as their mentors. Insights: Family physicians were highly motivated to become LFME preceptors of 1st-year medical students. Whereas they consistently valued the relationships built during the academic year with the students assigned to them, they also considered that exchanges did not always happen without difficulties, and gauged the roles they played as complex, ambiguous, and necessarily evolving over time.

Transition to Pediatric Practice: A Residency Elective Experience to Prepare Senior Pediatric Residents for General Pediatric Primary Care

INTRODUCTION

Transition to practice (TTP), while impactful in other specialties, has been minimally studied and rarely offered in pediatric training residency programs. This pediatric TTP elective is designed to provide a glimpse into the world of a primary care pediatrician to residents who are interested in pursuing a career in primary care.

METHODS

During this elective residents hone their outpatient diagnostic skills by participating in a variety of clinical patient encounters; this is supplemented with selectives, learner-chosen supplemental educational activities that aim to help fulfill a resident's self-identified learning goals. This TTP experience was developed for third-year pediatric residents who are planning on entering primary care. The course is organized and facilitated by a general pediatric faculty member with an administrative assistant.

RESULTS

This TTP elective was evaluated highly by pediatric residents; the overall score of its effectiveness, rated by residents who participated in the elective, was 4.5-5.0 out of 5.0. Following completion of this TTP elective, residents demonstrated an overall improvement in outpatient procedural opportunities and self-reported competence for routine outpatient procedures. In addition, residents demonstrated an overall improvement in office-visit billing practices.

DISCUSSION

The 4-week rotation format maximizes the number of general pediatric outpatient clinical experiences and individualized learning selectives.

Medical students developing confidence and patient centredness in diverse clinical settings: a longitudinal survey study

BACKGROUND

Medical student clinical confidence and positive attitudes to patient centredness are important outcomes of medical education. The clinical placement setting is regarded as a critical support to these outcomes, so understanding how the setting is influential is important. The aim of this study was to compare students' attitudes towards patient-centredness and clinical confidence as they progressed through their medical course, and understand the influence of diverse clinical placement zones.

METHODS

Students at one Australian medical school completed a questionnaire at the beginning of second year and at the end of their third year of medical training. The questionnaire measured attitudes to patient centred care, clinical confidence, role modelling experiences and clinical learning experiences. Descriptive analyses investigated change in these attitudes over time. Repeated measures analysis of variance was used to assess the influence of placement location on each variable of interest. Responses to two open-ended questions were also coded by two researchers and themes were identified.

RESULTS

Student confidence increased over the course of two years of clinical training (p < 0.001), but attitudes to patient centredness (p = 0.933) did not change. The location of clinical placements (urban, outer urban and rural) was unrelated to levels of confidence or patient centredness. Students had positive attitudes towards patient-centredness throughout, and noted its importance in contributing to quality care. Patient-centred care was encouraged within the clinical placements, and was influenced by positive and negative role modelling, direct teaching, and opportunities to practise patient-centred care.

CONCLUSIONS

A new generation of doctors with a strong patient-centred focus is emerging. Medical schools have a responsibility to facilitate clinical placements that will support the acquisition and maintenance of skills in patient centred care through positive role modelling.

Problem-based learning: Dental student's perception of their education environments at Qassim University

Aims:

The objectives of this study were to assess perceptions of the Saudi dental students of the problem-based learning (PBL) curriculum and to compare their perceptions among different sex and academic years.

Subjects and Methods:

Data was collected through a questionnaire-based survey at Qassim College of dentistry. The questionnaire consisted of 19 questions regarding the perception of PBL curriculum and was distributed to 240 students. The chi-square test was used for statistical analysis of the data.

Results:

Out of the 240 students recruited for this study, 146 returned a complete questionnaire (the response rate was 60.8%). The majority of the students perceived that PBL enhances the ability to speak in front of people (91.1%); improved the ability to find the information using the internet/library (81.5%); enhances the problem-solving skills (71.3%); increases the practice of cooperative and collaborative learning (69.2%); improves the decision-making skills (66.4%). Sixty-five percent (n = 96) noted that some students dominate whereas others are passive during PBL discussion session. Statistically, significant differences were found in the following variables according to the academic year students assuming before responsibility for their own learning (P < 0.037) and the role of facilitator in the process (P < 0.034). Moreover, according to gender; there were statistically significant differences in the following variables, assuming responsibility for own learning (P < 0.003); activating prior knowledge and learning to elaborate and organize their knowledge (P < 0.009); enhancing the ability to find the information using the Internet/library (P < 0.014); PBL is effective without having lecture of the same topic (P < 0.025); helping in identifying the areas of weakness for improvement (P < 0.031); student understanding the objectives of the PBL session better than the conventional way (P < 0.040); and enhancing the ability to speak in front of people (P < 0.040).

Conclusions:

Perceptions of Saudi dental students regarding their education environments at Qassim College of dentistry using PBL hybrid curriculum were more positive than negative. However, improvements are still required to provide students with stimulating favorable learning environment and to take the students recommendations into consideration.

Educational interventions to improve prescribing competency: a systematic review

OBJECTIVE

To review the literature on educational interventions to improve prescribing and identify educational methods that improve prescribing competency in both medical and non-medical prescribers.

DESIGN

A systematic review was conducted. The databases Medline, International Pharmaceutical Abstracts (IPA), EMBASE and CINAHL were searched for articles in English published between January 1990 and July 2013.

SETTING

Primary and secondary care.

PARTICIPANTS

Medical and non-medical prescribers.

INTERVENTION

Education-based interventions to aid improvement in prescribing competency.

PRIMARY OUTCOME

Improvements in prescribing competency (knows how) or performance (shows how) as defined by Miller's competency model. This was primarily demonstrated through prescribing examinations, changes in prescribing habits or adherence to guidelines.

RESULTS

A total of 47 studies met the inclusion criteria and were included in the systematic review. Studies were categorised by their method of assessment, with 20 studies assessing prescribing competence and 27 assessing prescribing performance. A wide variety of educational interventions were employed, with different outcome measures and methods of assessments. In particular, six studies demonstrated that specific prescribing training using the WHO Guide to Good Prescribing increased prescribing competency in a wide variety of settings. Continuing medical education in the form of academic detailing and personalised prescriber feedback also yielded positive results. Only four studies evaluated educational interventions targeted at non-medical prescribers, highlighting that further research is needed in this area.

CONCLUSIONS

A broad range of educational interventions have been conducted to improve prescribing competency. The WHO Guide to Good Prescribing has the largest body of evidence to support its use and is a promising model for the design of targeted prescribing courses. There is a need for further development and evaluation of educational methods for non-medical prescribers.

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.

Teaching musculoskeletal clinical skills to medical trainees and physicians: a Best Evidence in Medical Education systematic review of strategies and their effectiveness: BEME Guide No. 18

BACKGROUND

Musculoskeletal (MSK) complaints make up 12-20% of primary health visits and are a source of significant expenditures and morbidity. Despite this, MSK examination is an area of weakness among practising physicians. Several studies have highlighted the need for increased MSK physical exam teaching. However, increased teaching time alone does not guarantee improvement in these skills. Thus, we aimed to identify interventions that are effective in promoting transfer of MSK clinical skills.

METHODS

The review protocol was approved by the Best Evidence in Medical Education (BEME) organization. A comprehensive search was conducted and systematic review methods were applied. Data were not pooled statistically due to heterogeneity.

RESULTS

About 5089 titles were screened; 24 studies were included. Eighteen of 24 studies focused on undergraduate medical education. Five of nine studies favoured patient educator. Five of six studies favoured interactive small groups, two of four studies favoured computer-assisted learning, and two of two studies favoured peer learning. Individual studies demonstrated effectiveness of reminder sheets and Gait Arms Legs Spine teaching, respectively.

CONCLUSIONS

This study supports the use of different instructional methods that engage learners and provide meaningful learning contexts. The majority of the studies support patient educators and interactive small group teaching.

The effects of audience response systems on learning outcomes in health professions education. A BEME systematic review: BEME Guide No. 21

BACKGROUND

Audience response systems (ARS) represent one approach to make classroom learning more active. Although ARS may have pedagogical value, their impact is still unclear. This systematic review aims to examine the effect of ARS on learning outcomes in health professions education.

METHODS

After a comprehensive literature search, two reviewers completed title screening, full-text review and quality assessment of comparative studies in health professions education. Qualitative synthesis and meta-analysis of immediate and longer term knowledge scores were conducted.

RESULTS

Twenty-one of 1013 titles were included. Most studies evaluated ARS in lectures (20 studies) and in undergraduates (14 studies). Fourteen studies reported statistically significant improvement in knowledge scores with ARS. Meta-analysis showed greater differences with non-randomised study design. Qualitative synthesis showed greater differences with non-interactive teaching comparators and in postgraduates. Six of 21 studies reported student reaction; 5 favoured ARS while 1 had mixed results.

CONCLUSION

This review provides some evidence to suggest the effectiveness of ARS in improving learning outcomes. These findings are more striking when ARS teaching is compared to non-interactive sessions and when non-randomised study designs are used. This review highlights the importance of having high quality studies with balanced comparators available to those making curricular decisions.

Educators must consider patient outcomes when assessing the impact of clinical training

CONTEXT

The concept of outcomes has been used in health care for over 140 years. The use of outcomes in assessing quality of care regained prominence in the 1960s based on Donabedian's framework of structures, processes and outcomes. In the 1990s, the use of outcomes in medical education gained great favour, although the outcomes used were not carefully defined. Recently, a debate has ensued about the costs and, thus, sustainability of current health care programmes, focusing on the (non-)necessity of services, missed prevention opportunities and the efficiency of treatment programmes. Measurements using education outcomes and health care outcomes must take these issues into account, preferably from a common framework. As health care becomes increasingly costly and even inefficient, issues of effectiveness are often neglected in policy making.

METHODS

This paper uses peer-reviewed evidence and an outcomes framework to explore the implications of current realities for the makers of education policy in the health professions and for the staff who train health professionals.

DISCUSSION

If the ultimate impacts of practices and policies in health professions education are not considered, how will we know if our education structures, processes and outcomes are optimal? This essay examines this question from the perspectives of three related issues. The first refers to the need for a common framework if the outcomes of patient and community care are to be evaluated properly. The second perspective refers to whether it is feasible to consider both patient-based outcomes and patient-reported outcomes in assessing the impact of education programmes, especially at more advanced levels of training. The third perspective concerns the challenges and limitations that may be encountered in focusing on patient outcomes as a measure of the impact of education. The concluding discussion suggests how the results of such longer-term impact studies should be interpreted as key validity checks on the quality and effectiveness of medical education and clinical education if we are to address the validity and efficiency of outcomes used in education and training.

Graduates from a reformed undergraduate medical curriculum based on Tomorrow's Doctors evaluate the effectiveness of their curriculum 6 years after graduation through interviews

BACKGROUND

In 1996 Liverpool reformed its medical curriculum from a traditional lecture based course to a curriculum based on the recommendations in Tomorrow's Doctors. A project has been underway since 2000 to evaluate this change. This paper focuses on the views of graduates from that reformed curriculum 6 years after they had graduated.

METHODS

Between 2007 and 2009 45 interviews took place with doctors from the first two cohorts to graduate from the reformed curriculum.

RESULTS

The interviewees felt like they had been clinically well prepared to work as doctors and in particular had graduated with good clinical and communication skills and had a good knowledge of what the role of doctor entailed. They also felt they had good self directed learning and research skills. They did feel their basic science knowledge level was weaker than traditional graduates and perceived they had to work harder to pass postgraduate exams. Whilst many had enjoyed the curriculum and in particular the clinical skills resource centre and the clinical exposure of the final year including the "shadowing" and A & E attachment they would have liked more "structure" alongside the PBL when learning the basic sciences.

CONCLUSION

According to the graduates themselves many of the aims of curriculum reform have been met by the reformed curriculum and they were well prepared clinically to work as doctors. However, further reforms may be needed to give confidence to science knowledge acquisition.

Problem-based learning in academic health education. A systematic literature review

Problem based learning (PBL) arguably represents the most significant development in education over the past five decades. It has been promoted as the curriculum of choice, and since its introduction in the 1960's, has been widely adopted by many medical and dental schools. PBL has been the subject of much published literature but ironically, very little high quality evidence exists to advocate its efficacy and subsequently justify the widespread curriculum change. The purpose of this review is to classify and interpret the available evidence and extract relevant conclusions. In addition, it is the intent to propose recommendations regarding the relative benefits of PBL compared with conventional teaching. The literature was searched using PubMed, ERIC and PsycLIT. Further articles were retrieved from the reference lists of selected papers. Articles were chosen and included according to specific selection criteria. Studies were further classified as randomised controlled trials (RCTs) or comparative studies. These studies were then analysed according to intervention type: whole curricula comparisons and single educational interventions of shorter duration. At the level of RCTs and comparative studies (whole curricula), no clear difference was observed between PBL and conventional teaching. Paradoxically, it was only comparative studies of single PBL intervention in a traditional curriculum that yielded results that were consistently in favour of PBL. Further research is needed to investigate the possibility that multiple PBL interventions in a traditional curriculum could be more effective than an exclusively PBL programme. In addition, it is important to address the potential benefits of PBL in relation to life-long learning of health care professionals.

Problem-based learning in pre-clinical medical education: 22 years of outcome research

PURPOSE

To conduct a systematic review of problem-based learning (PBL) in undergraduate, pre-clinical medical education.

METHODS

A research librarian developed comprehensive search strategies for MEDLINE, PSYCINFO, and ERIC (1985-2007). Two reviewers independently screened search results and applied inclusion criteria. Studies were included if they had a comparison group and reported primary data for evaluative outcomes. One reviewer extracted data and a second reviewer checked data for accuracy. Two reviewers independently assessed methodological quality. Quantitative synthesis was not performed due to heterogeneity. A qualitative review with detailed evidence tables is provided.

RESULTS

Thirty unique studies were included. Knowledge acquisition measured by exam scores was the most frequent outcome reported; 12 of 15 studies found no significant differences. Individual studies demonstrated either improved clerkship (N = 3) or residency (N = 1) performance, or benefits on some clinical competencies during internships for PBL (N = 1). Three of four studies found some benefits for PBL when evaluating diagnostic accuracy. Three studies found few differences of clinical (or practical) importance on the impact of PBL on practicing physicians.

CONCLUSIONS

Twenty-two years of research shows that PBL does not impact knowledge acquisition; evidence for other outcomes does not provide unequivocal support for enhanced learning. Work is needed to determine the most appropriate outcome measures to capture and quantify the effects of PBL. General conclusions are limited by methodological weaknesses and heterogeneity across studies. The critical appraisal of previous studies, conducted as part of this review, provides direction for future research in this area.

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

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

Factors influencing mammography participation in Canada: an integrative review of the literature

This integrative review critically examines quantitative and qualitative evidence concerning factors influencing the participation of Canadian women in mammography. Empirical studies published between 1980 and 2006 were identified and retrieved by searching electronic databases and references listed in published studies. Among the 1461 citations identified and screened, 52 studies met the inclusion criteria and were independently appraised by two researchers. Extracted data were categorized, summarized, compared, and interpreted within and across studies. The presentation of barriers and facilitators to mammography was guided by the Pender Health Promotion Model. Findings from this review showed that no published studies were specific to settings in Saskatchewan, Nova Scotia, Prince Edward Island, Newfoundland and Labrador, and the three Canadian territories. The most common barriers to screening were membership in an ethnic minority and concerns about pain, radiation, and embarrassment. The recommendation of a health care provider for mammography was found to be the most common facilitator for the engagement of women in this health behaviour. The targeting of specific strategies aimed at overcoming identified barriers and the enhancement of facilitators are essential to improving mammography participation rates throughout Canada.

Toward meeting the challenge of physician competence assessment: the University of California, San Diego Physician Assessment and Clinical Education (PACE) Program

Physician competence and performance problems contribute to medical errors and substandard health care quality. Assessment of the clinical competence of practicing physicians, however, is challenging. Although physician competence assessment undoubtedly does take place at the local level (e.g., hospital, medical group), it is difficult to objectively assess a partner, colleague, or friend. Moreover, the methodologies used and the outcomes are necessarily veiled by peer review statutes. Consequently, there is a need for regional or national assessment centers with the knowledge, skill, and experience to perform clinical competence assessments on individual physicians and provide or direct remediation, when appropriate. The University of California, San Diego (UCSD) Physician Assessment and Clinical Education (PACE) Program was founded at the UCSD School of Medicine in 1996 for this purpose. From inception in 1996 through the first quarter of 2009, 867 physicians have participated in the UCSD PACE Program. The PACE Program is divided into two components. Phase I includes two days of multilevel, multimodal testing, and Phase II is a five-day, preceptor-based formative assessment program taking place in the residency program of the physician's specialty. From July 2002 through December 2005, a study of 298 physician participants of the UCSD PACE Program was conducted.The future of the comprehensive assessment of practicing physicians depends on (1) development and standardization of instruments, techniques, and procedures for measuring competence and performance, including in-practice measures, (2) collaborative networking of assessment programs, (3) cost control, and (4) continued development of remedial measures that correspond to assessment findings.

Predicting doctor performance outcomes of curriculum interventions: problem-based learning and continuing competence

CONTEXT

Problem-based learning (PBL) is an educational strategy designed to enhance self-assessment, self-directed learning and lifelong learning. The present study examines a peer review programme to determine whether the impact of PBL on continuing competence can be detected in practice.

OBJECTIVES

This study aimed to establish whether McMaster graduates who graduated between 1972 and 1991 were any less likely to be identified as having issues of competence by a systematic peer review programme than graduates of other Ontario medical schools.

METHODS

We identified a total of 1166 doctors who had graduated after 1972 and had completed a mandated peer review programme. Of these, 108 had graduated from McMaster and 857 from other Canadian schools. School of graduation was cross-tabulated against peer rating. A secondary analysis examined predictors of ratings using multiple regression.

RESULTS

We found that 4% of McMaster graduates and 5% of other graduates were deemed to demonstrate cause for concern or serious concern, and that 24% of McMaster doctors and 28% of other doctors were rated as excellent. These differences were not significant. Multiple regression indicated that certification by family medicine or a specialty, female gender and younger age were all predictors of practice outcomes, but school of graduation was not.

CONCLUSIONS

There is no evidence from this study that PBL graduates are better able to maintain competence than graduates of conventional schools. The study highlights potential problems in attempting to link undergraduate educational interventions to doctor performance outcomes.

Problem-based learning and larger student groups: mutually exclusive or compatible concepts - a pilot study

BACKGROUND

Problem-based learning is recognised as promoting integration of knowledge and fostering a deeper approach to life-long learning, but is associated with significant resource implications. In order to encourage second year undergraduate medical students to integrate their pharmacological knowledge in a professionally relevant clinical context, with limited staff resources, we developed a novel clustered PBL approach. This paper utilises preliminary data from both the facilitator and student viewpoint to determine whether the use of this novel methodology is feasible with large groups of students.

METHODS

Students were divided into 16 groups (20-21 students/group) and were allocated a PBL facilitator. Each group was then divided into seven subgroups, or clusters, of 2 or 3 students wh each cluster being allocated a specific case. Each cluster was then provided with more detailed clinical information and studied an individual and distinct case-study. An electronic questionnaire was used to evaluate both student and facilitator perception of this clustered PBL format, with each being asked to rate the content, structure, facilitator effectiveness, and their personal view of the wider learning experience.

RESULTS

Despite initial misgivings, facilitators managed this more complex clustered PBL methodology effectively within the time restraints and reported that they enjoyed the process. They felt that the cases effectively illustrated medical concepts and fitted and reinforced the students' pharmacological knowledge, but were less convinced that the scenario motivated students to use additional resources or stimulated their interest in pharmacology. Student feedback was broadly similar to that of the facilitators; although they were more positive about the scenario stimulating the use of additional resources and an interest in pharmacology.

CONCLUSION

This clustered PBL methodology can be successfully used with larger groups of students. The key to success lies with challenging and well situated clinically relevant cases together with enthusiastic facilitators. Facilitator enjoyment of the PBL process may be related to adequate training and previous PBL experience, rather than academic background. The smaller number of facilitators required using this clustered PBL approach allows for facilitators with 'a belief in the philosophy of PBL' to volunteer which would again impact on the success of the process.

The effects of problem-based learning during medical school on physician competency: a systematic review

BACKGROUND

Systematic reviews on the effects of problem-based learning have been limited to knowledge competency either during medical school or postgraduate training. We conducted a systematic review of evidence of the effects that problem-based learning during medical school had on physician competencies after graduation.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Databases, and the tables of contents of 5 major medical education journals from earliest available date through Oct. 31, 2006. We included studies in our review if they met the following criteria: problem-based learning was a teaching method in medical school, physician competencies were assessed after graduation and a control group of graduates of traditional curricula was used. We developed a scoring system to assess the quality of the studies, categorized competencies into 8 thematic dimensions and used a second system to determine the level of evidence for each competency assessed.

RESULTS

Our search yielded 102 articles, of which 15 met inclusion criteria after full text review. Only 13 studies entered final systematic analysis because 2 studies reported their findings in 2 articles. According to self-assessments, 8 of 37 competencies had strong evidence in support of problem-based learning. Observed assessments had 7 competencies with strong evidence. In both groups, most of these competencies were in the social and cognitive dimensions. Only 4 competencies had moderate to strong levels of evidence in support of problem-based learning for both self-and observed assessments: coping with uncertainty (strong), appreciation of legal and ethical aspects of health care (strong), communication skills (moderate and strong respectively) and self-directed continuing learning (moderate).

INTERPRETATION

Problem-based learning during medical school has positive effects on physician competency after graduation, mainly in social and cognitive dimensions.

[Experience with new teaching methods and testing in psychiatric training]

In 1999, the Charité Medical University in Berlin, Germany, implemented a reformed medical study course (RMSC) along with traditional undergraduate medical education. The RMSC is characterized by problem-based learning (PBL), training in communication skills with "simulated patients", and interdisciplinary seminars. The curriculum is organized into blocks according to organ system and age (period od life). In a new intensive 4-week psychiatric block, 4th-year students get practical experience in psychiatric wards. Furthermore, PBL groups and workshops are offered that focus on frequent psychiatric disorders. By providing interactive courses with simulated patients, students are intensively trained in taking psychiatric histories and in generating psychopathological findings. Defined learning objectives are tested using multiple-choice items and objectively structured clinical examinations at semester end. First positive results indicate that this course represents an appropriate and practicable curriculum for teaching psychiatry in Germany.

Revitalizing problem based learning: student and tutor attitudes towards a structured tutorial

BACKGROUND

The pre-clinical curriculum at the University of New Mexico School of Medicine is a hybrid model that includes small group, problem-based learning (PBL) tutorials and didactic lectures. A structured tutorial format was piloted for the human sexuality/reproduction organ system block for the PBL component. The objective of this study was to compare the acceptability of the structured format and its effectiveness with that of a traditional PBL tutorial.

METHODS

Students were surveyed after the renal/endocrinology block of 2004 (traditional tutorial format) and after the human sexuality/reproduction block of 2004 (structured tutorial format) (n = 70). Survey questions covered the quality of learning and of tutorial. Students (n = 132) and tutors (n = 24) who participated in human sexuality/reproduction in 2004 and 2005 were surveyed for attitudes about the structured tutorial overall and specific components. Means of responses were compared using t-tests.

RESULTS

Students indicated that the structured tutorial format supported a greater improvement in their basic science and clinical knowledge and their ability to evaluate information (p < 0.05). The majority of students and tutors recommended the structured format for tutorials in other blocks.

CONCLUSIONS

We demonstrated the acceptability of a structured tutorial format to students and faculty. Faculty members perceived greater depth of learning and participation by the students.

Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning

OBJECTIVE

To develop a model linking the processes and outcomes of workplace learning.

METHODS

We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students.

RESULTS

To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning.

CONCLUSIONS

The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Fitness for purpose evaluation in problem based learning should consider the requirements for establishing descriptive causation

Debate continues about what existing evaluations of the impact of Problem Based Learning tell us and about how future evaluations should be designed. This paper argues that establishing descriptive causation should be an important goal of such evaluations. Minimizing threats to internal validity is of key importance to establishing descriptive causation. It is argued that whilst not a panacea randomized experiments offer particular advantages in this respect. This is illustrated through comparison of examples of evaluations of Problem Based Learning that have used different types of study design.

Lack of integration of medical education in Australia: the need for change

The lack of cohesion across health and education sections and national and state jurisdictions is counterproductive to effective national policies in medical education and training. Existing systems in Australia for medical education and training lack coordination, and are under resourced and under pressure. There is a need for a coordinated national approach to assessment of international medical graduates, and for meeting their education and training needs. The links between prevocational and vocational training must be improved. Tensions between workforce planning, education and training can only be resolved if workforce and training agencies work collaboratively. All prevocational positions should be designed and structured to ensure that service, training, teaching and research are appropriately balanced. There is a need for more health education research in Australia.