Cognitive apprenticeship in clinical practice: can it stimulate learning in the opinion of students?

Learning in clinical practice can be characterised as situated learning because students learn by performing tasks and solving problems in an environment that reflects the multiple ways in which their knowledge will be put to use in their future professional practice. Collins et al. introduced cognitive apprenticeship as an instructional model for situated learning comprising six teaching methods to support learning: modelling, coaching, scaffolding, articulation, reflection and exploration. Another factor that is looked upon as conducive to learning in clinical practice is a positive learning climate. We explored students’ experiences regarding the learning climate and whether the cognitive apprenticeship model fits students’ experiences during clinical training. In focus group interviews, three groups of 6th-year medical students (N = 21) discussed vignettes representing the six teaching methods and the learning climate to explore the perceived occurrence of the teaching methods, related problems and possibilities for improvement. The students had experienced all six teaching methods during their clerkships. Modelling, coaching, and articulation were predominant, while scaffolding, reflection, and exploration were mainly experienced during longer clerkships and with one clinical teacher. The main problem was variability in usage of the methods, which was attributed to teachers’ lack of time and formal training. The students proposed several ways to improve the application of the teaching methods. The results suggest that the cognitive apprenticeship model is a useful model for teaching strategies in undergraduate clinical training and a valuable basis for evaluation, feedback, self-assessment and faculty development of clinical teachers.     

Diuresis cystometry versus filling cystometry: The diagnostic value of diuresis cystometry in patients with frequency,urgency, and/or urge incontinence complaints

Filling cystometry was performed in 16 asymptomatic patients. Cystometry under high diuretic conditions (diuresis cystometry) was also performed in 37 asymptomatic patients. It appeared that diuresis cystometry is not more complicated than filling cystometry. The prevalence of detrusor instability in the asymptomatic groups is independent of the type of cystometry. Diuresis cystometry was performed in 36 patients with frequency, urgency, and/or urge incontinence, in whom the prevalence of instability during filling cystometry was comparable with that found in the asymptomatic patients. It appeared that the prevalence of instability in the symptomatic group is significantly higher than in the asymptomatic group during diuresis cystometry. This difference is even much higher with respect to the prevalence of detrusor instability with pressure rises of more than 15 cm H₂O.     

Trends in research on the tutor in problem-based learning: conclusions and implications for educational practice and research

The tutor role in problem-based learning (PBL) has attracted the interest of many researchers and has led to an abundance of studies. This article reports on major trends in studies investigating the tutor during the past 10 years. Three major trends were observed by the authors while analysing the studies conducted: studies on the differential influence of content expert and non-content expert tutors on student achievement, studies on process variables, and studies on the relationship between tutor characteristics and differential contextual circumstances. The aim of this article is to summarize the main findings of the studies conducted so far within the three trends observed, to provide directions for educational practitioners and policy makers, and to suggest directions for future research questions. The studies included were selected by conducting a literature search in medical journals, which was complemented with the personal archives of the authors. The results of the studies conducted within the three trends of research have led to advanced insights in tutoring. The outcomes revealed that content expert tutors tend to use their subject-matter expertise more to direct the discussion in the tutorial group, whereas non-content expert tutors tend to use their process-facilitation expertise more to direct the tutorial group. Furthermore, a tutor's performance is not a stable characteristic but is partly situation specific. It is concluded that a tutor should both know how to deal with the subject matter expertise and should know how to facilitate the learning process. Faculty and policy makers should put substantial efforts into designing curricula and cases and developing tutors' skills by faculty development strategies that stimulate reflection. The research agenda should be driven more by modern educational theories of learning in which tutoring is a process aimed at stimulating constructive, self-directed, situated and collaborative learning by students. Furthermore, more qualitative studies should be conducted to gain better insights in teachers' conceptions about the tutor role and student learning to better understand their behaviours.     

Clerkship assessment assessed

This article reviews consistent research findings concerning the assessment of clinical competence during the clerkship phase of the undergraduate medical training programme on issues of reliability, validity, effect on training programme and learning behaviour, acceptability and costs. Subsequently, research findings on the clinical clerkship as a learning environment are discussed demonstrating that the clinical attachment provides a rather unstructured educational framework. Five fundamental questions (why, what, when, how, who) are addressed to generate general suggestions for improving assessment on the basis of the evidence on assessment and clinical training. Good assessment requires a thoughtful compromise between what is achievable and what is ideal. It is argued that educational effects are eminently important in this compromise, particularly in the unstructured clinical setting. Maximizing educational effects can be achieved in combination with improvements of other measurement qualities of the assessment. Two concrete examples are provided to illustrate the recommended assessment strategies.     

Validation of a short questionnaire to assess the degree of complexity and structuredness of PBL problems

BACKGROUND: In problem-based learning (PBL), problems represent the starting point of students' learning activities. Therefore, the quality of these problems should be high, in that they should be of an adequate level of complexity and structuredness. Previous research has proposed several guidelines for constructing problems, but some of them are rather vague and are not based on empirical evidence. The present study aimed to validate a short questionnaire that can be used to assess the degree of complexity and structuredness of PBL problems. METHOD: This paper outlines Jonassen's theory, on which the questionnaire is based, and its relationship and applicability to PBL problems. The questionnaire was validated by means of confirmatory factor analysis. RESULTS: The results showed that students were able to distinguish PBL problems that were too simple and those that were too well-structured, but found it difficult to distinguish problems that were too complex or too ill-structured. CONCLUSION: The questionnaire may be used to measure the levels of complexity and structuredness of a problem as perceived by students and can provide teachers with feedback about the quality of problems.     

Detection of a nosocomial outbreak of salmonellosis may be delayed by application of a protocol for rejection of stool cultures

In October 2001 an outbreak of Salmonella enterica serovar enteritidis phage-type 6 occurred in a hospital and a nursing home, both served by the same hospital kitchen. Five nursing home residents died during the outbreak. S. enteritidis was isolated from three of them. Of 231 stool samples from nursing home residents, hospital patients and employees, 82 were culture-positive. All symptomatic patients were treated with oral ciprofloxacin. Inspection of the kitchen showed that during preparation of the desserts implicated in causing the outbreak, temperatures were not measured and storage temperatures were too high. No left-over food samples were available for analysis. According to the 'four-day rule' in use in this hospital, the stool samples related to the first outbreak were not cultured for Salmonella spp., whereas culturing afterwards from both stored specimens and repeats, showed that some of these samples would have been positive for S. enteritidis. Thus without the application of stool culture rejection criteria the outbreak would have been detected one day earlier. With the four-day rule in effect, the outbreak might have been detected much later, if an unusually high number of nursing home residents with gastroenteritis had not been noticed by nursing home physicians. The rule was revised to prevent a possible delay in the future. As a result of this outbreak, the government has announced legislation forbidding the sale of Salmonella-contaminated eggs. An official ban on the use of raw eggs will be included in several hygiene codes.     

Infantile osteopetrosis; bone marrow transplantation from a cousin donor

The successful correction of infantile osteopetrosis in an Asian child by bone marrow transplantation (BMT) from an HLA-A,B matched cousin donor is reported. Retrospective HLA molecular analysis revealed that patient and donor were incompatible for HLA-DPB1. Donor type cells detected in the patient after transplantation indicate successful engraftment. The patient is currently alive and well.