Adoption of Problem-Based Learning in Medical Schools in Non-Western Countries: A Systematic Review

Phenomenon: In recent decades, medical education practices developed in Western countries have been widely adopted in non-Western countries. Problem-based Learning (PBL) was first developed in North America and it relies on Western educational and cultural values, thereby raising concerns about its 'lift and shift' to non-Western settings. Approach: This review systematically identified and interpretively synthesized studies on students' and teachers' experiences of PBL in non-Western medical schools. Three databases (ERIC, PsycINFO, and MEDLINE) were searched. Forty-one articles were assessed for quality using the Critical Appraisal Skills Program (CASP) checklist and synthesized using meta-ethnography. The final synthesis represented over 5,400 participants from 18 countries. Findings: Findings were categorized into three different constructs: Student Engagement, Tutor Skills, and Organization and Planning. Our synthesis demonstrates that medical students and teachers in non-Western countries have varied experiences of PBL. Students engage variably with PBL, consider knowledge to be better acquired from authoritative figures, and deem PBL to be ineffective for assessment preparation. Student participation is limited by linguistic challenges when they are not native English speakers. Teachers are often unfamiliar with the underlying philosophical assumptions of PBL and struggle with the facilitation style needed. Both students and teachers have developed modifications to ensure that PBL better fits in their local settings. Insights: Given the significant adjustments and resource requirements needed to adopt PBL, medical school leaders and policy makers in non-Western countries should carefully consider possible consequences of its implementation for their students and teachers, and proactively consider ways to 'hybridize' it for local contexts.

Implementation of virtual OSCE in health professions education: A systematic review

INTRODUCTION

The Objective Structured Clinical Examination (OSCE) has been widely used in health professions education since the 1970s. The global disruption caused by the COVID-19 pandemic restricted in-person assessments and medical educators globally sought alternative means to assess and certify students and trainees to meet the acute demand for health-care workers. One such solution was through virtual OSCE (vOSCE), which modified traditional in-person OSCE using videoconference platforms. This meta-ethnography sought to synthesise qualitative literature on candidates' and assessors' experiences of vOSCE to evaluate whether it may have a role in future assessment practices.

METHODS

In June 2022, we systematically searched PsycINFO, Medline and ERIC for peer-reviewed qualitative and mixed-methods articles that described candidates' and assessors' experiences of virtual OSCE in health professions education. Of 1069 articles identified, 17 were synthesised using meta-ethnography.

RESULTS

The final synthesis represented 1190 candidates and assessors from faculties of medicine, dentistry, nursing, pharmacy and osteopathy. We developed our findings into four key concepts. 'Strengthening confidence in a virtual environment' highlighted attempts to overcome and mitigate concerns associated with transitioning from in-person to virtual assessment. 'Understanding the scope of use as an assessment' reflected on the suitability of vOSCE in assessing various skills. 'Refining operational processes' emphasised the technical challenges of implementing vOSCE and impacts on accessibility and resources. 'Envisioning its future role' considered the applicability of vOSCE in the climate of rapid development in telehealth.

CONCLUSION

This meta-ethnography highlighted that although vOSCE was primarily considered a temporary and crisis response, candidates and assessors recognised positive, as well as negative, consequences of the transition towards them. Moving forward, medical education policymakers should carefully consider the extent to which elements of vOSCE could be incorporated into assessment systems, particularly in light of the rise of telehealth in clinical practice.

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

BACKGROUND

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment.

METHODS

All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals.

RESULTS

A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death.

CONCLUSION

Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Understanding impacts of accreditation on medical teachers and students: A systematic review and meta-ethnography

PURPOSE

Accreditation is widely used by medical schools around the word to evaluate their curricula and educational processes, although its impacts on those involved in the 'frontline' of medical education receive little attention. This study systematically identified and synthesised qualitative studies that have explored medical teachers' and students' experiences of accreditation.

METHODS

Four databases (Pubmed, EMBASE, ERIC, and PsychINFO) were searched for relevant published articles. Synthesis was performed using meta-ethnography.

RESULTS

Eighteen articles were included in the final synthesis with 1017 individual participants from 10 countries. Findings were categorised into four domains, including navigating power differentials, evaluating credibility, influencing medical programmes, and culture and behaviour. The synthesis demonstrates divergent views on the value of accreditation in medical schools from students and staff including both positive and negative impacts on medical education programmes and stakeholders.

CONCLUSIONS

Although accreditation is perceived to have many benefits, it also has a number of unintended consequences, including on staff morale, student-teacher relationships, and teacher workloads. Medical teachers also have a number of concerns about the credibility of accreditation standards, assessors, and processes. Regulators and policymakers should consider the views of teachers and students as they seek to improve current accreditation practices.

For Students, by Students: a Peer-Led Entrepreneurship Course for Medical Students

Recognising the growing importance of clinical leadership and entrepreneurship to implement innovative healthcare solutions, final year UK medical students developed a near-peer elective module for first- and second-year students. To date, five cohorts have completed the module and developed skills in the fields of medical technology, quality improvement, and leadership.

Levelling the playing field: students' motivations to contribute to an amnesty of assessment materials

BACKGROUND

'Exam recall' is a recognised phenomenon whereby students recall and record questions after leaving the examination hall. This poses two main problems. First, as these questions are only available to peers of the students who recall the questions, these individuals have an unfair advantage. Secondly, the distribution of these recalled questions poses a threat to the validity and defensibility of assessments. To address the first of these problems, we developed an amnesty enabling students to submit assessment material to an on-line site. This study sought to explore which factors influence students' contributions to an amnesty of assessment material.

METHODS

We conducted a qualitative study using semi-structured focus groups. We used convenience sampling and recruited participants from all years of our undergraduate medical programme. The focus groups were facilitated by a medical student peer to reduce the power imbalance and encourage participants to discuss candidly. The focus groups were audio recorded and transcribed verbatim. Two researchers independently analysed all transcripts using thematic analysis and the research team met regularly to discuss emergent findings. Nvivo was used to assist with thematic analysis of the transcripts.

RESULTS

Twenty-six individuals participated in six focus groups. Six themes were identified through the analysis, which were categorised into motivating factors and de-motivating factors. Motivating factors were a perception that this would overcome inequity, a fear of repercussions, and the perceived usefulness of resources. Factors that prevented students contributing were a culture of competition, a lack of incentives, and mistrust of the medical school.

CONCLUSIONS

The establishment of an amnesty was acceptable to students and they were motivated to contribute materials. The competitive nature of medical careers and the stakes of summative assessments meant that students felt that some peers might still not contribute their materials. Students felt that the school were listening to their concerns and this led to a better dialogue between students and faculty.

Endosonographic monitoring of transurethral cryoprostatectomy

Cryoprostatectomy, the use of subzero temperatures to ablate prostate tissue gained favour in the 1960s because of its speed and lack of haemodynamic effects. It fell from use because the freezing process could not be monitored and this led to a high incidence of local complications. We have performed transrectal real time ultrasound in 12 patients undergoing cryoprostatectomy. In all the freezing process was easily visualized as an advancing hyperechoic 'iceball' with distal acoustic shadowing. Monitoring allowed maximum prostate ablation without breaching the prostatic capsule. There were no significant complications and all but one patient gained symptomatic relief. Ultrasound at 1 month showed a heterogeneous echo pattern with very little cavity formation but by 3 months a significant cavity was seen. This study demonstrates that it is possible to monitor the freezing process during transurethral cryoprostatectomy. This, theoretically, should significantly reduce the local complications encountered in previous studies.

Head injuries in a general surgical unit

A five years' experience of the care by general surgeons of patients with severe head injuries in a general surgical unit with inferior facilities was retrospectively reviewed. It was concluded that the mortality compared favourably with that in similar patients managed by neurosurgeons in specialized centres. The still inadequate understanding of primary diffuse brain damage in head injuries is suggested as the cause for this lack of significant improvement in results over the years. Certain guide-lines, however, exist to allow prediction of the eventual outcome in these patients.