A tutor programme in obstetrics and gynaecology

A Tutor Programme was created in a third-year clerkship in obstetrics and gynaecology to remedy a student complaint of insufficient contact with teaching staff. Data obtained through the use of observational methodologies were integrated with data from questionnaires and student/teacher interviews to assess programme content, its contribution to student education, and the characteristics of student-teacher interactions. Teachers and students both expressed satisfaction at this opportunity to 'get to know each other'. A unique contribution of the programme was the discussion of a set of topics categorized as 'Medicine as a Career and Lifestyle', e.g. how to make career decisions, residency selection, etc.). These topics were not addressed elsewhere in the curriculum yet were of great importance to the students. The value of observational methods in comprehensive programme evaluation was reaffirmed.     

A computer-based test item-bank for cognitive assessment of medical students during a clinical medicine clerkship

The development and utilization of multiple-choice test items and the utilization of computer technology have significantly altered evaluation practices in medical schools. This paper describes the development and implementation of a computer-based multiple-choice test item-bank for use in a junior medicine clerkship. The computer program, ITEMBANK, is an interactive system that stores and edits test items and constructs and prints an original copy of each test. Tests can be produced almost immediately by the clerical staff and the total developmental costs have been minimal. The program has reduced the amount of teaching time required to develop tests, and has enhanced the learning of essential information by medical students and residents. Teaching staff and student response has been enthusiastic and positive. Statistically significant Pearson correlation coefficients have been obtained between student performance on these tests and clinical evaluation and NBME Part II scores. The program has made a valuable contribution to the improvement of evaluation procedures in the Internal Medicine clerkship.     

The introduction of problem-based learning projects into a clinical correlation course in the first year of the Edinburgh medical curriculum

Thirty hours were allotted to problem-based learning projects in the first year of a new medical curriculum in Edinburgh. Those projects have been very successful in encouraging student initiative and in satisfying the students'desire for contact with patients, relatives and medical staff early in the curriculum. The difficulties involved in this form of teaching and the shortcomings of the exercise are discussed.     

Congruence between student and instructor perceptions of clinical teaching in paediatrics

The purpose of this study was to examine the similarities and differences in what students and instructors perceive to be the importance, and instructor use of, representative effective clinical teaching skills noted in the literature. Teaching staff members (n = 74) and students (n = 96) in three successive quarters in a required clerkship in paediatrics completed parallel forms of a clinical teaching survey. Providing feedback and positive reinforcement, showing personal interest in students, communicating knowledge and learning objectives effectively, motivating students, exhibiting knowledge of current practice and physical diagnosis, and spending time reviewing histories and demonstrating and supervising physical examinations were all thought to be important by both students and teaching staff members. Both students and instructors, however, perceived history/physical examination skills to be somewhat less important than the other clinical teaching skills, although instructors believed this skill to be significantly more important than did students. In general there was a great deal of consistency and reliability among student and instructor perceptions of the importance of these representative effective clinical teaching skills. In contrast, teaching staff members consistently believed they used each skill significantly more than students judged they did. Not surprisingly, the more important that teaching staff members believed each skill to be, the more they reported using that skill in their own teaching. These findings suggest that it is important for clinical instructors to be vigilant in assessing the effectiveness of their teaching methods.     

Changes in students' perceptions of clinical teaching as a result of general-practice clerkships

This study investigated whether a 3-week clerkship for third-year medical students in general-practice doctors' offices changed the students' perceptions of clinical teaching. The Preceptor Evaluation Questionnaire was administered to 138 junior medical students before and after their clerkships. The result of the study indicated that the clerkship had a positive effect on the students' perceptions. This finding was not related to their experiences in other clerkships nor to the grades they received for the clerkship.
The results indicate that the teaching relationship established between student and family doctor significantly affects students' perceptions of aspects of effective clinical teaching.     

Clinical clerkships: students can structure their own learning

In clinical clerkships, student learning is often unstructured and diverse. Even when curriculum objectives are explicit, they are seldom used by students to guide their learning. Student-determined learning objectives may help students to structure their learning. This study aimed to assess whether students can use this method to meet widely differing learning needs within the general practice clerkship and considered the relationship of student objectives to overall curriculum objectives. Students allocated a 5-week clerkship in general practice from April 2000 to April 2001 were required to set and meet personal learning objectives within a supportive learning environment. They recorded the strategies they used, how well objectives were met and which curriculum objectives they met. Objectives were categorised using a hierarchical system. A total of 143 (85%) students recorded 1549 objectives. Four categories accounted for 1092 (70%) of objectives: Consultation Skills; Study of Diseases; Practical Procedures, and Therapeutics. Otherwise the range of objectives set was wide, encompassing all curriculum objectives. A total of 1043 objectives were rated as satisfactorily or highly satisfactorily met and 185 (12%) were not met at all. Strategies that students used to meet objectives included clinical experience with doctors but also with practice-based nurses. Students were able to use student-determined learning objectives to meet a diverse range of learning needs within the general practice clerkship. The objectives set reflected the breadth of curriculum objectives. This method allows students to address gaps in their knowledge in a clerkship where teaching is largely based on opportunistic contact.     

Factors modifying duration of drug action: a practical for large undergraduate classes on limited laboratory space, staff and budget

A desperate need for health professionals is answered by yearly increases in university student admissions in many developing countries. Yet economic constraints dictate that subventions for teaching and research remain static or even decrease as student populations increase. Practical teaching, for example in pharmacology, is susceptible to inadequate funding because of the capital and recurrent expenditure needed to procure and maintain laboratories, staff, animals, instruments and chemicals. Class demonstrations, although they provide a partial answer to the problem, are beset with a number of disadvantages. Provision of good training on low funds demands ingenuity to modify teaching/learning processes while still achieving the desired objectives. This paper illustrates such a procedure by describing the logistics of a practical class on 'Factors modifying duration of drug action' to large classes of undergraduate medical and pharmacy students, on limited laboratory space, staff and budget'. A sample laboratory result is included.     

A conference on ethics for obstetric and gynaecological clerkship students

Integrating the teaching of medical ethics into medical students' clinical education is challenging, given the competing demands on students' time and the need for teaching to be clinically relevant. This paper describes a model programme for incorporating ethics teaching into the obstetrics and gynaecology clerkship for third-year medical students. The programme is taught by two attending teachers and a medical ethicist with experience teaching in the clinical setting of obstetrics and gynaecology. Objective pretests and posttests showed substantial improvement in students' knowledge, and student feedback has been very positive.     

Televised paediatric consultations: a student evaluation of a multipurpose learning strategy

Since 1984, each student in the sixth-year paediatric rotation in the Department of Paediatrics and Child Health at the University of the Witwatersrand has been videotaped while undertaking a comprehensive paediatric primary care consultation. Video replay of the consultation by each individual student was evaluated by the student together with medical and social work tutors. This incorporated psychosocial aspects, communication skills, doctor-mother-child interactions, as well as essential medical content, clinical examination techniques, and management strategies. The student was expected to provide comprehensive health care, viz. dealing with the presenting health problems, identifying any possible hidden agenda, giving due attention to nutrition, immunization, development, optimal use of available records, health surveillance and appropriate education. This teaching programme was introduced in 1984. In 1988, 68 consecutive final-year medical students completed an anonymous Likert-type evaluation form scoring their perceived learning. They affirmed that the use of television in medical education provides a unique multipurpose learning strategy and in particular enhances awareness of self and of patient/family needs. The time, cost and effort invested in this programme are considered justified.     

The surgical clerkship: characteristics of the effective teacher

A good relationship between medical students and clinicians is crucial to a positive learning experience. To increase contact between surgical teaching staff and students, a teacher programme was instituted in the problem-based surgical clerkship at the University of Kentucky. This study examined the teacher traits and skills that medical students perceive as distinguishing effective from ineffective teachers. The 312 evaluations collected from students in successive surgical clerkship rotations (87% response rate) were used to determine the characteristics of the effective teacher. Results suggest that students rate increased contact with surgical teaching staff highly and that they value increased mentoring by the staff. The traits of teachers rated highly by students in the surgical clerkship include: being a positive role model, encouraging communication, and being well organized. Comparing data from the 2 years of the clerkship also revealed that providing feedback to staff on their performance as teachers enabled them to improve their instructional skills.     

Performance of medical students in case-based and essay components of written anatomy examinations

This paper reports on second-year medical students' performance in the case-based and traditional essay components of the gross anatomy written examinations at the University of Otago held at the end of 1988 and 1989. The mean marks for these two components of the examinations are presented for the three main categories of student entry. Differential performance on the case-based component relative to the essay component has been determined for each student in the class and ranked in order. The proportions of students in the three entry categories falling in the various quartiles for the class are given. The data show that when an intensive programme of case-based learning was followed, as in 1988, all three categories performed similarly on the case-based component relative to the essay component. When a less intensive programme of case-based learning was used, as in 1989, the differential performance of the preferential undergraduate and graduate categories was different to each other. The findings suggest that the achievement of students in the case-based projects is dependent upon the organization of the programme and the extent to which students and staff become involved in the projects. The writing of reports on the cases by students for assessment in 1988 may have had an important influence on the outcome for this year.     

A factor analytic study of teaching in off-campus general practice clerkships

The Preceptor-evaluation questionnaire (PEQ) was developed at the University of Mississippi Medical Center to evaluate the clinical teaching behaviour of general practice doctors in private practice who have one or more third-year medical students per year in their offices for a required general practice clerkship. The PEQ was designed to provide feedback to these doctors and the sponsoring department in an effort to improve teaching in this setting. Developed from the input of family practice doctors who have supervised students in their offices and from a review of related literature, the instrument was given to students to determine the level of importance they attributed to each teaching characteristic. A principle components factor analysis and subsequent varimax rotation produced six significant teaching factors in this setting. These six factors were:

• 1 demonstrates a humanistic orientation toward patients and staff;
• 2 demonstrates a humanistic orientation toward student;
• 3 provides opportunity for practice;
• 4 motivates and stimulates student's thinking;
• 5 communicates effectively with student; and
• 6 demonstrates comfort and confidence in the roles of doctor and teacher.

The factor relating to the humanistic orientation toward student has not appeared as a separate factor in other studies of clinical teaching. This may be due to the unique aspects of the relationship between student and doctor in this setting which may not occur in other settings. The PEQ and similar reliable and valid instruments can provide valuable information for the doctors in these off-campus teaching situations as well as provide useful programme planning information for the sponsoring academic departments. This information may also be valuable for off-campus residency training.     

Influence of clerkship experiences on clinical competence

BACKGROUND: Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear. OBJECTIVES: This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence. METHODS: Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software. RESULTS: Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters. CONCLUSION: Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.     

The clinical learning environments in medicine, paediatrics and surgery clerkships

Using questionnaires, the students of the 1981 graduating class from McGill's Faculty of Medicine were investigated for their perceptions of the nature of the clinical instruction and of the roles of the consultant, resident and intern staffs during clerkships in medicine, paediatrics and surgery. Personal student diaries were used to assess time spent on various clinical activities. The results indicated that students perceived learning to be different in the three disciplines, with the acquisition of clinical skills (technical and problem-solving skills) greater in medicine and surgery than in paediatrics, and the acquisition of interpersonal skills and factual knowledge greater in paediatrics than in medicine and surgery. Students perceived themselves as passive observers in surgery and formed personal relationships more easily with staff in medicine and paediatrics than in surgery. In contrast, students perceived more emphasis on team effort in surgery. Time spent on activities related to direct patient encounter was greatest in medicine. The findings suggest that the learning environments in clinical disciplines are not homogeneous and this has implications for curricular planning and clinical teaching.     

Learning preferences, computer attitudes, and student evaluation of computerised instruction

OBJECTIVE: To explore the relationship between learning preferences, attitudes towards computers, and student evaluation of a computer-assisted instructional (CAI) program. CONTEXT: A third year required clerkship in surgery at the University of Nebraska Medical Center. METHODS: A mixed-methods design combining attitudinal measures and qualitative interviews was employed to assess student reactions to a CAI program on angiography completed during a required surgical clerkship. Between January 1998 and July 1999, 151 students completed the program. Prior to participating, students completed the Rezler Learning Preference Inventory (LPI) and a computer attitudes survey (CAS). The LPI characterizes learning preferences as being abstract or concrete, individual or interpersonal, and student-structured or teacher-structured. The CAS measures attitudes towards computers and their role in education. After using the CAI program, students evaluated the module by completing an 18 item questionnaire. Based on LPI and CAS scores, 31 students were invited to participate in an in-depth qualitative interview on their experiences and perceptions of the program. RESULTS: There was no relationship between learning preferences, computer attitudes, and evaluation of the CAI program. Students were very positive about the program's content, clarity, organization, and ease of use. They also rated it as efficient and effective. However, many still indicated a preference for lecture and text-based learning. Qualitative interviews suggest students worry computers will supplant student--teacher contact. CONCLUSIONS: Learning preferences and prior attitudes toward computers did not bias student reactions to the CAI program assessed in this study. However, students expressed concerns that CAI would interfere with the traditional student--teacher encounter and relationship.     

What do students actually do on an internal medicine clerkship? A log diary study

BACKGROUND: There are limited data on the amount of time students spend on teaching and learning while on internal medicine clerkships, and existing data suggest a wide international variation. Community-based teaching of internal medicine is now widespread; but its strengths and weaknesses compared to traditional hospital based teaching are still unclear. AIM: To determine the proportion of time students spend on different activities on an internal medicine clerkship, and to determine whether this differs in general practice and in hospital. In addition we aimed to determine students' views on the educational value and enjoyment of various activities. METHODS: Prospective completion of log diaries recording student activities. Each student was asked to complete the diary for two separate weeks of their internal medicine clerkship: one week of general practice-based teaching and one week of hospital-based teaching. RESULTS: The response rate was 68% (88/130). Students spent approximately 5.5 h per day on teaching and learning activities in both environments, with more time (50 min vs. 30 min, P = 0.007) on unsupervised interaction with patients in hospital than in general practice, and more time (53 min vs. 21 min, P < 0.001) undergoingassessment in general practice than in hospital. Standard deviations were wide, demonstrating the heterogeneous nature of the data. Students perceived supervised interaction with patients and teaching by doctors as the most educational activities in both environments, but found it even more educationally valuable and enjoyable in general practice than in hospital (mean score for educational value: 4.27 in general practice, 3.88 in hospital, P = 0.048; mean score for enjoyment 4.13 in general practice, 3.66 in hospital, P = 0.03). CONCLUSIONS: Students greatly value interactions with patients, perceiving these as both educational and enjoyable. Curriculum planners must continue to place patient-based learning at the centre of undergraduate medical education. The heterogeneity of the data suggests that individual students have very different experiences, despite apparently similar timetables.     

Reliability and validity of the objective structured clinical examination in paediatrics

The assessment of clinical competence has traditionally been carried out through standard evaluations such as multiple choice question and bedside oral examinations. The attributes which constitute clinical competence are multidimensional, and we have modified the objective structured clinical examination (OSCE) to measure these various competencies. We have evaluated the validity and reliability of the OSCE in a paediatric clinical clerkship. We divided the examination into the four components of competence (clinical skills, problem-solving, knowledge, and patient management) and evaluated the performance of 77 fourth-year medical students. The skill and content domains of the OSCE were carefully defined, agreed upon, sampled and reproduced. This qualitative evaluation of the examination was both adequate and appropriate. We achieved both acceptable interstation and intertask reliability. When correlated with concurrent methods of evaluation we found the OSCE to be an accurate measure of paediatric knowledge and patient management skills. The OSCE did not correlate, however, with traditional measures of clinical skills including history-taking and physical examination. Our OSCE, as outlined, offers an objective means of identifying weaknesses and strengths in specific areas of clinical competence and is therefore an important addition to the traditional tools of evaluation.     

Establishing a psychiatry clerkship in a clinical teaching unit

Difficulties arising during the establishment of a clinical unit students' clerkship programme are presented. These are reviewed to establish general principles important for the successful introduction of such clerkships. Particular emphasis is laid on continual evaluation, and the results of one such evaluation are discussed.     

Standardized patients: a long-station clinical examination format

Summary. Data from the first 20 periods of a long-station clinical performance examination for a 4-week required clerkship in family medicine were examined in order to assess the reliability and validity of the examination. Data from 304 students were examined for station, case scenario and examiner effects and results compared to short-station formats. A significant examiner effect was found but there were no differences in student performance for station or case scenario. These findings reflect examiner specificity cited in the literature for short station examinations, but not case specificity. The source of variability for this examination appears to be primarily examiner effect. There was a significant correlation between student scores on the two cases, and raters tended to rank order students similarly in spite of variability in mean rater score. Scores on the CPE correlated with other measures of clinical performance as well as other methods of student evaluation for the clerkship providing some evidence for construct and criterion-related validity. CPE cases were developed from clerkship objectives but examination of the test blueprint revealed some gaps in the extent to which the CPE covers the course content. CPE developers are working to increase interrater reliability through examiner training and further standardize case scenarios through checklists and patient training. Additional cases are being developed to increase the content validity of the examination.     

Undergraduate medical education in obstetrics and gynaecology in the USA and Canada, 1985

Many factors have led to a movement from the emphasis of the 1960s and 1970s on departmental expansion towards an emphasis on cost-effective undergraduate medical education emphasizing the 'art' as well as the 'science' of medicine. In January 1985 a questionnaire was sent under the auspices of the Undergraduate Education Committee of the Association of Professors of Obstetrics and Gynecology to all chairmen of departments of obstetrics and gynecology in the USA and Canada seeking their opinions about these trends and information about the educational programmes in their departments. The information from this study indicates that the chairmen are aware of and responding to this new direction in medical education. A stabilization of teaching staff and clerkship sizes and the emphasis on clinical as well as cognitive evaluation, despite recognition of the cost of the former, shows active interventions towards these ends. An emphasis on education in 'basic' as compared to 'subspecialty' areas which is independent of the subspecialty of the academic chairman also supports this trend.