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

REVIEW DATE

Review period January 1992-December 2001. Final analysis July 2004-January 2005. BACKGROUND AND REVIEW CONTEXT: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. OBJECTIVES OF REVIEW: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research.

SEARCH STRATEGY

Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of:Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology.

CRITERIA

DEFINITIONS

EXPERIENCE

Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included.

EXCLUSIONS

Not empirical; not early; post-basic; simulated rather than 'authentic' experience.

DATA COLLECTION

Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation.

HEADLINE RESULTS

A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention.

CONCLUSIONS

Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Well-being and treatment satisfaction in older people with diabetes

OBJECTIVE

To measure well-being and treatment satisfaction and their correlates in older people with diabetes.

RESEARCH DESIGN AND METHODS

A postal survey was conducted of 1,000 diabetic patients aged > or = 60 years, representing 56% of the resident older diabetic population in an inner-city health district with a largely indigenous population of 230,000 people and a widely varied socioeconomic mix. Well-being and treatment satisfaction were measured with diabetes-specific instruments and correlated with patient data held in a central register.

RESULTS

There was an 81% response. The general well-being scores (median [interquartile range]) for patients on diet alone, tablets, and insulin were 54 (44-60), 53 (42-61), and 48 (35-56) (P < 0.001 comparing insulin with diet and tablets) compared with a scale maximum of 66. Treatment satisfaction scores were 35 (31-36), 35 (32-36), and 34 (30-36) (P < 0.001 comparing insulin with diet and tablets), scale maximum 36. Mean HbA1c concentrations were 5.0 +/- 1.4% (for patients on diet alone), 5.8 +/- 1.6% (tablets), and 6.6 +/- 1.7% (insulin) (P < 0.001 for each difference). Neither well-being nor treatment satisfaction correlated with HbA1c. Insulin-treated patients were younger and had been diabetic longer than non-insulin-treated patients; their well-being remained slightly, but significantly, lower when adjusted for age, sex, BMI, and diabetes duration, but treatment satisfaction was no longer significantly different. Women had lower well-being than men.

CONCLUSIONS

It has proved possible to measure well-being and treatment satisfaction in a large community-based samples of older people with diabetes. At the level of glycemic control in this population, neither parameter correlated with HbA1c. The lower well-being in insulin-treated patients remained significant in multivariate analysis.

The diabetes educator: trying hard, but must concentrate more on behaviour

Current guidelines state that education is fundamental to help people with diabetes modify their lifestyle and prevent ill health and early death. However, many people with diabetes are not receiving adequate education. There is a widespread assumption that transferring knowledge will improve health outcomes but there is little empirical support for this assertion. Indeed, knowledge and behaviour are poorly correlated. Knowledge may be a necessary condition but is rarely a sufficient condition for behaviour change. Single interventions, cognitive or behavioural, have had disappointing results, unsurprisingly given the complexity of human behaviour. The most effective interventions are multifaceted and include education, behavioural and psychosocial elements, and target lifestyle change and factors such as self-efficacy and empowerment. We advocate that educational interventions should have multiple components. They should aim to improve patients' sense of self-efficacy and empowerment, and build attitudes towards diabetes that will support the lifestyle changes needed for successful self-management. These conclusions have implications for future research and clinical practice.

How do clinicians become teachers? A communities of practice perspective

There is widespread acceptance that clinical educators should be trained to teach, but faculty development for clinicians is undermined by poor attendance and inadequate learning transfer. As a result there has been growing interest in situating teacher development initiatives in clinical workplaces. The relationship between becoming a teacher and clinical workplace contexts is under theorised. In response, this qualitative research set out to explore how clinicians become teachers in relation to clinical communities and institutions. Using communities of practice (CoP) as a conceptual framework this research employed the sensitising concepts of regimes of competence and vertical (managerial) and horizontal (professional) planes of accountability to elucidate structural influences on teacher development. Fourteen hospital physicians completed developmental timelines and underwent semi-structured interviews, exploring their development as teachers. Despite having very different developmental pathways, participants' descriptions of their teacher identities and practice that were remarkably congruent. Two types of CoP occupied the horizontal plane of accountability i.e. clinical teams (Firms) and communities of junior doctors (Fraternities). Participants reproduced teacher identities and practice that were congruent with CoPs' regimes of competence in order to gain recognition and legitimacy. Participants also constructed their teacher identities in relation to institutions in the vertical plane of accountability (i.e. hospitals and medical schools). Institutions that valued teaching supported the development of teacher identities along institutionally defined lines. Where teaching was less valued, clinicians adapted their teacher identities and practices to suit institutional norms. Becoming a clinical educator entails continually negotiating one's identity and practice between two potentially conflicting planes of accountability. Clinical CoPs are largely conservative and reproductive of teaching practice whereas accountability to institutions is potentially disruptive of teacher identity and practice.

Factors protective against retinopathy in insulin-dependent diabetics free of retinopathy for 30 years

To investigate which factors might protect against the development of retinopathy 40 insulin-dependent diabetics who had remained free from retinopathy despite diabetes of long duration (mean+/-1 SD 30+/-10 years) were compared with 40 patients who had background and 47 who had proliferative retinopathy (mean durations of disease 16+/-5 and 19+/-5 years respectively). The three groups had had similar mean ages at onset of diabetes. The mean of all postprandial blood glucose measurements at hospital clinics from diagnosis of diabetes to detection of retinopathy, or to the most recent negative eye examination, was 9.9+/-2.1 mmol/l (178+/-38 mg/100 ml) in the group with no retinopathy, 11.8+/-2.1 mmol/l (213+/-38 mg/100 ml) in those with background retinopathy, and 12.4+/-2.1 mmol/l (223+/-38 mg/100 ml) in those with proliferative retinopathy (p <0.0001). This difference was not reflected in present concentrations of haemoglobin A(1C), probably because glycaemic control had been improved after the development of retinopathy. In the groups with background and proliferative retinopathy there were significant negative correlations between mean blood glucose concentrations and the number of years that had elapsed from diagnosis of diabetes to detection of retinopathy, suggesting that the development of both grades of retinopathy depends on the degree and duration of glycaemic exposure.The patients with no retinopathy had attended clinic more frequently (p <0.025), more of them had required emergency hospital treatment for hypoglycaemia (p <0.0025), and they tended to have had a lower prevalence of hyperglycaemic coma than the other groups. Although mean percentage ideal body weight and diastolic blood pressure were lower in the patients with no retinopathy at the time of study, mean body weight, blood pressure, and the prevalence of smoking in the years before the development of retinopathy had been similar in all groups, suggesting that these did not influence the development of retinopathy.

How do people with Type 2 diabetes perceive and respond to cardiovascular risk?

OBJECTIVES

To explore how people with Type 2 diabetes perceive cardiovascular risk, and how those perceptions might affect their motivation to make lifestyle changes.

METHODS

The setting was a diabetes clinic in a UK teaching hospital. A qualitative study was conducted, using semistructured individual interviews and template analysis of content. The participants were 20 Type 2 diabetic patients, aged between 52 and 77 years, half with and half without cardiovascular disease (CVD).

RESULTS

Whether they had CVD or not, most people were aware they were at risk of it, of its causative factors, and possible effects. However, they were more likely to attribute it to unchangeable factors like 'stress' and 'heredity', than medical risk factors like cholesterol and smoking. Patients with pre-existing CVD correctly regarded their risk as higher than those without. Few saw any direct link between being diabetic per se and cardiovascular risk. Lifestyle changes were precipitated by major life events and motivated by family support, fear of complications, and a belief that one should follow doctors' advice. A common reaction to CVD and diabetes was stoical acceptance, allowing patients to view their lives positively, whilst living with unpredictable potentially disabling diseases.

CONCLUSIONS

Patients were unaware how strongly diabetes influences cardiovascular risk. Their ideas about risk were very different from those of conventional medicine, and provided individual rationales for making choices about treatment and risk-influencing behaviour. Contextual factors, such as family milieu, also influenced their behaviour. Clinicians should not assume patients share the same mental model of risk as they, and must be prepared to explore peoples' individual constructs and health beliefs.

Swimbladder morphology masks Southern Ocean mesopelagic fish biomass

Within the twilight of the oceanic mesopelagic realm, 200-1000 m below sea level, are potentially vast resources of fish. Collectively, these mesopelagic fishes are the most abundant vertebrates on Earth, and this global fish community plays a vital role in the function of oceanic ecosystems. The biomass of these fishes has recently been estimated using acoustic survey methods, which rely on echosounder-generated signals being reflected from gas-filled swimbladders and detected by transducers on vessels. Here, we use X-ray computed tomography scans to demonstrate that several of the most abundant species of mesopelagic fish in the Southern Ocean lack gas-filled swimbladders. We also show using catch data from survey trawls that the fish community switches from fish possessing gas-filled swimbladders to those lacking swimbladders as latitude increases towards the Antarctic continent. Thus, the acoustic surveys that repeatedly show a decrease in mesopelagic fish biomass towards polar environments systematically overlook a large proportion of fish species that dominate polar seas. Importantly, this includes lanternfish species that are key prey items for top predators in the region, including king penguins and elephant seals. This latitudinal community switch, from gas to non-gas dominance, has considerable implications for acoustic biomass estimation, ecosystem modelling and long-term monitoring of species at risk from climate change and potential exploitation.

Making sense of how physician preceptors interact with medical students: discourses of dialogue, good medical practice, and relationship trajectories

Work based learning and teaching in health care settings are complex and dynamic. Sociocultural theory addresses this complexity by focusing on interaction between learners, teachers, and their environment as learners develop their professional identity. Although social interaction between doctors and students plays a crucial role in this developmental process, socio-cultural research from the perspective of doctors is scarce. We performed discourse analysis on seven general practitioners' audio diaries during a 10-week general practice clerkship to study how they gave shape to their interaction with their students. Examination of 61 diary-entries revealed trajectories of developing relationships. These trajectories were initiated by the way respondents established a point of departure, based on their first impression of the students. It continued through the development of dialogue with their student and through conceptualizations of good medical practice. Such conceptualizations about what was normal in medical and educational practice enabled respondents to recognize qualities in the student and to indirectly determine students' desired learning trajectory. Towards the end, discursive turns in respondents' narratives signaled development within the relationship. This became evident in division of roles and positions in the context of daily practice. Although respondents held power in the relationships, we found that their actions depended strongly on what the students afforded them socially. Our findings address a gap in literature and could further inform theory and practice, for example by finding out how to foster constructive dialogue between doctors and students, or by exploring different discourses among learners and teachers in other contexts.

Evaluation of self-directed clinical education: validation of an instrument

AIM

To explore the evaluation of self-directed, integrated clinical education.

METHODS

We delivered a quantitative and qualitative, self-report questionnaire to students through their web-based learning management system. The questionnaire was distributed 4 times over 1 year, each time in 2 parts. A generic part evaluated boundary conditions for learning, teaching activities and "real patient learning". Factor analysis with varimax rotation was used to validate the constructs that made up the scale and to stimulate hypotheses about how they interrelated. A module-specific part evaluated real patient learning of the subject matter in the curriculum.

RESULTS

A total of 101 students gave 380 of a possible 404 responses (94%). The generic data loaded onto 4 factors, corresponding to: firm quality; hospital-based teaching and learning; community and out-patient learning, and problem-based learning (PBL). A 5-item quality index had content, construct and criterion validity. Quality differed greatly between firms. Self-evaluation of module-specific, real patient learning was also valid. It was strongly influenced by the specialty interests of hospital firms.

CONCLUSIONS

Quality is a multidimensional construct. Self-report evaluation of real patient learning is feasible, and could be capitalised on to promote reflective self-direction. The social and material context of learning is an important dimension of educational quality.

Capillary and venous blood glucose measurements using a direct glucose-sensing meter

The aim of the study was to evaluate the precision and accuracy of the ExacTech home blood glucose meter when used with either capillary or venous blood and to compare this with a reference whole blood glucose assay. Non-fasting glucose measurements were used since a validation study showed no capillary-venous differences between fasting and post-prandial states. In a cross-sectional study, blood was taken from 182 patients and measured in duplicate on three batches of strips. Altogether we analysed 1089 readings. The regression of the data from capillary blood samples (meter vs reference method) had a correlation coefficient, of 0.93, and a mean bias of 0.2 mmol l-1. The corrected 90% confidence interval was +/- 1.5 mmol l-1 overall, and +/- 0.9 mmol l-1 for readings under 7.0 mmol l-1. Regression of the data from venous blood samples (meter vs reference method) had a correlation coefficient of 0.93 and a slope of x 1.1. The corrected 90% confidence interval was +/- 1.7 mmol l-1. Thus venous blood may be used even though the meter is calibrated for capillary samples but the value must be corrected by dividing by 1.1. Error-grid analysis showed that day-to-day clinical decisions could be made on the basis of ExacTech readings, although a diagnosis of borderline diabetes may not be possible.

The influence of reflection on portfolio learning in undergraduate dental education

INTRODUCTION

Disparity exists between the growing consensus about the positive effects of reflection on performance and the scarcity of empirical evidence demonstrating this effect. Portfolios are considered a useful instrument to assess and supervise competence-based education and to stimulate reflection. The present study describes the introduction of a portfolio in a social dentistry and oral health promotion course and investigates student reflection as a predictor for the acquisition of the other competences in the course.

METHODS

Fourth year undergraduate dental students (n = 110) in the course 'Society and Health' between 2008 and 2011 collected evidence in their portfolios, demonstrating the acquisition of five competences: the ability to (1) assess the oral health profile of a target group; (2) integrate theoretical models in health promotion; (3) search for and apply scientific evidence; (4) work trans-, multi- and/or trans-disciplinarily; (5) reflect on personal development. Linear regression analysis was used to investigate the predictive value of reflection on the other course related competences.

RESULTS

Reflection scores proved to significantly predict other course-related competences, when analysing all students between 2008 and 2011 and for each year separately, explaining between 10.7% and 25.5% of the variance in the other competences.

CONCLUSION

Undergraduate dental students' competences related to social dentistry and oral health promotion were significantly predicted by the reflection scores obtained in a portfolio-based context. In line with the growing consensus about the benefits of reflection for dental students and professionals, results suggest the value to further develop the integration of reflection in dental education and practice.

Glucose regulation of glucagon secretion independent of B cell activity

To investigate whether glucose has an effect on the pancreatic A cell independent of intraislet or paracrine B cell mediation, we have tested the ability of changes in plasma glucose (PG) level to influence the acute glucagon response (AGR) to 5 g of intravenous arginine in 8 C-peptide negative insulin dependent diabetics (IDD). Insulin was infused (1 mU/kg/min) for a 90 min basal period during which PG levels were maintained constant by the glucose clamp technique. Basal AGR was then determined. In 4 of the diabetics, the PG level was subsequently lowered to a new steady state and, in 2 diabetics, PG level was raised. In 2 additional IDDs, two manipulations in PG level were carried out (PG ranges 51-390 mg/dl). The same insulin infusion was continued throughout. The acute glucagon response to arginine was determined at each PG level. The ability of unit changes in PG to influence (modulate) the AGR (MdIRG) was calculated as the difference in AGRs divided by the PG difference. MdIRG was consistent between diabetics (means +/- SEM = 2.1 +/- 0.2) and was independent of both direction and magnitude of the PG change. Thus, in vivo, in man, glucose has an effect on the pancreatic A cell which is independent of intraislet B cell influences.

Productivity and Change in Fish and Squid in the Southern Ocean

Southern Ocean ecosystems are globally important and vulnerable to global drivers of change, yet they remain challenging to study. Fish and squid make up a significant portion of the biomass within the Southern Ocean, filling key roles in food webs from forage to mid-trophic species and top predators. They comprise a diverse array of species uniquely adapted to the extreme habitats of the region. Adaptations such as antifreeze glycoproteins, lipid-retention, extended larval phases, delayed senescence, and energy-conserving life strategies equip Antarctic fish and squid to withstand the dark winters and yearlong subzero temperatures experienced in much of the Southern Ocean. In addition to krill exploitation, the comparatively high commercial value of Antarctic fish, particularly the lucrative toothfish, drives fisheries interests, which has included illegal fishing. Uncertainty about the population dynamics of target species and ecosystem structure and function more broadly has necessitated a precautionary, ecosystem approach to managing these stocks and enabling the recovery of depleted species. Fisheries currently remain the major local driver of change in Southern Ocean fish productivity, but global climate change presents an even greater challenge to assessing future changes. Parts of the Southern Ocean are experiencing ocean-warming, such as the West Antarctic Peninsula, while other areas, such as the Ross Sea shelf, have undergone cooling in recent years. These trends are expected to result in a redistribution of species based on their tolerances to different temperature regimes. Climate variability may impair the migratory response of these species to environmental change, while imposing increased pressures on recruitment. Fisheries and climate change, coupled with related local and global drivers such as pollution and sea ice change, have the potential to produce synergistic impacts that compound the risks to Antarctic fish and squid species. The uncertainty surrounding how different species will respond to these challenges, given their varying life histories, environmental dependencies, and resiliencies, necessitates regular assessment to inform conservation and management decisions. Urgent attention is needed to determine whether the current management strategies are suitably precautionary to achieve conservation objectives in light of the impending changes to the ecosystem.

Child health and obstetrics-gynaecology in a problem-based learning curriculum: accepting the limits of integration and the need for differentiation

BACKGROUND AND OBJECTIVES

The University of Manchester's undergraduate curriculum was reorganised in 1994. Problem-based learning (PBL) was chosen as the central educational method throughout the 5 years. A thematic interdisciplinary style provided a framework around which to select and integrate content. The theme for family, reproductive and child health for the 14-week Families and Children Module (FCM) in year 4 integrated content from obstetrics-gynaecology, paediatrics (including child psychiatry), genetics and public health. This paper focuses on the FCM which has put to test some of the principles of integration.

METHODS

The educational process and outcome of the FCM was evaluated with information from (1) Open Forum feedback sessions (2) student questionnaires and (3) students' performance in an objective structured clinical examination (OSCE).

RESULTS

Significant problems were encountered during the first year of the FCM (1997--98). An Open Forum for all students and staff was convened after each module in order to address the level of concern. Students' responses to questionnaires reflected the overall impression obtained from the Open Forum. Difficulties appeared to be more than the anxieties and challenges inherent in organisational change and were not simple practical timetabling problems. Tutors perceived a loss of coherence and student contact; students reported difficulties maintaining sufficient continuity of focus in clinical and academic learning experiences. The intended level of integration of paediatrics and obstetrics-gynaecology was unmanageable. Consequently, the FCM (1998-99) was divided into separate attachments for clinical learning and experience in paediatrics and obstetrics-gynaecology, each of 7 weeks' duration. Further open feedback sessions revealed that the modifications implemented in 1998-99 were associated with positive experiences for students and tutors. Comparison of responses to the evaluation questionnaires showed that students' overall rating of the module was higher (P=0.002) for 1998-99 (mean 3.4, SD 0.9) than for 1997-98 (mean 3.0, SD 1.1).

CONCLUSIONS

We emphasise that horizontal integration can result in an experience of disintegration for students and tutors. Certain disciplines, such as paediatrics and obstetrics-gynaecology, may not have enough in common for full curriculum integration.

Large mesopelagic fish biomass in the Southern Ocean resolved by acoustic properties

The oceanic mesopelagic zone, 200-1000 m below sea level, holds abundant small fishes that play central roles in ecosystem function. Global mesopelagic fish biomass estimates are increasingly derived using active acoustics, where echosounder-generated signals are emitted, reflected by pelagic organisms and detected by transducers on vessels. Previous studies have interpreted a ubiquitous decline in acoustic reflectance towards the Antarctic continent as a reduction in mesopelagic fish biomass. Here, we use empirical data to estimate species-specific acoustic target strength for the dominant mesopelagic fish of the Scotia Sea in the Southern Ocean. We use these data, alongside estimates of fish relative abundance from net surveys, to interpret signals received in acoustic surveys and calculate mesopelagic biomass of the broader Southern Ocean. We estimate the Southern Ocean mesopelagic fish biomass to be approximately 274 million tonnes if Antarctic krill contribute to the acoustic signal, or 570 million tonnes if mesopelagic fish alone are responsible. These quantities are approximately 1.8 and 3.8 times greater than previous net-based biomass estimates. We also show a peak in fish biomass towards the seasonal ice-edge, corresponding to the preferred feeding grounds of penguins and seals, which may be at risk under future climate change scenarios. Our study provides new insights into the abundance and distributions of ecologically significant mesopelagic fish stocks across the Southern Ocean ecosystem.