Medical school dropout--testing at admission versus selection by highest grades as predictors

Medical Education 2011: 45 : 1111–1120 Context Very few studies have reported on the effect of admission tests on medical school dropout. The main aim of this study was to evaluate the predictive validity of non‐grade‐based admission testing versus grade‐based admission relative to subsequent dropout. Methods This prospective cohort study followed six cohorts of medical students admitted to the medical school at the University of Southern Denmark during 2002–2007 (n = 1544). Half of the students were admitted based on their prior achievement of highest grades (Strategy 1) and the other half took a composite non‐grade‐based admission test (Strategy 2). Educational as well as social predictor variables (doctor‐parent, origin, parenthood, parents living together, parent on benefit, university‐educated parents) were also examined. The outcome of interest was students’ dropout status at 2 years after admission. Multivariate logistic regression analysis was used to model dropout. Results Strategy 2 (admission test) students had a lower relative risk for dropping out of medical school within 2 years of admission (odds ratio 0.56, 95% confidence interval 0.39–0.80). Only the admission strategy, the type of qualifying examination and the priority given to the programme on the national application forms contributed significantly to the dropout model. Social variables did not predict dropout and neither did Strategy 2 admission test scores. Conclusions Selection by admission testing appeared to have an independent, protective effect on dropout in this setting.     

Adjusting medical school admission: assessing interpersonal skills using situational judgement tests

Context Today’s formal medical school admission systems often include only cognitively oriented tests, although most medical school curricula emphasise both cognitive and non‐cognitive factors. Situational judgement tests (SJTs) may represent an innovative approach to the formal measurement of interpersonal skills in large groups of candidates in medical school admission processes. This study examined the validity of interpersonal video‐based SJTs in relation to a variety of outcome measures. Methods This study used a longitudinal and multiple‐cohort design to examine anonymised medical school admissions and medical education data. It focused on data for the Flemish medical school admission examination between 1999 and 2002. Participants were 5444 candidates taking the medical school admission examination. Outcome measures were first‐year grade point average (GPA), GPA in interpersonal communication courses, GPA in non‐interpersonal courses, Bachelor’s degree GPA, Master’s degree GPA and final‐year GPA (after 7 years). For students pursuing careers in general practice, additional outcome measures (9 years after sitting examinations) included supervisor ratings and the results of an interpersonal objective structured clinical examination (OSCE), a general practice knowledge test and a case‐based interview. Results Interpersonal skills assessment carried out using SJTs had significant added value over cognitive tests for predicting interpersonal GPA throughout the curriculum, doctor performance, and performance on an OSCE and in a case‐based interview. For the other outcomes, cognitive tests emerged as the better predictors. Females significantly outperformed males on the SJT (d = ? 0.26). The interpersonal SJT was perceived as significantly more job‐related than the cognitive tests (d = 0.55). Conclusions Video‐based SJTs as measures of procedural knowledge about interpersonal behaviour show promise as complements to cognitive examination components. The interpersonal skills training received during medical education does not negate the selection of students on the basis of interpersonal skills. Future research is needed to examine the use of SJTs in other cultures and student populations.     

Admission criteria and diversity in medical school

Context

The under‐representation in medical education of students from lower socio‐economic backgrounds is an important social issue. There is currently little evidence about whether changes in admission strategies might increase the diversity of the medical student population. Denmark introduced an ‘attribute‐based’ admission track to make it easier for students who may not be eligible for admission on the ‘grade‐based’ track to be admitted on the basis of attributes other than academic performance. The aim of this research was to examine whether there were significant differences in the social composition of student cohorts admitted via each of the two tracks during the years 2002–2007.

Methods

This prospective cohort study included 1074 medical students admitted during 2002–2007 to the University of Southern Denmark medical school. Of these, 454 were admitted by grade‐based selection and 620 were selected on attributes other than grades. To explore the social mix of candidates admitted on each of the two tracks, respectively, we obtained information on social indices associated with educational attainment in Denmark (ethnic origin, father's education, mother's education, parenthood, parents living together, parent in receipt of social benefits).

Results

Selection strategy (grade‐based or attribute‐based) had no statistically significant effect on the social diversity of the medical student population.

Conclusions

The choice of admission criteria may not be very important to widening access and increasing social diversity in medical schools. Attracting a sufficiently diverse applicant pool may represent a better strategy for increasing diversity in the student population.     

Supporting student‐doctors from under‐resourced educational backgrounds: an academic development programme

Medical Education 2010: 44 : 917–925 Objectives Increased student diversity in medical schools is considered necessary. However, very few medical school applicants from under‐resourced educational backgrounds achieve competitive academic entrance scores. Pre‐admission development programmes that aim to produce competitive applicants may be inefficient in countries where under‐represented communities are majority populations. This study set out to determine: (i) whether an academic development programme (ADP) integrated into an existing South African medical training programme retained ADP students and enabled them to graduate within a reasonable period of time; (ii) the academic impact of the ADP, and (iii) whether performance in high school matriculation examinations predicted performance in medical school. Methods This retrospective study analysed records of medical students admitted between 1991 and 2001. Non‐ADP and ADP students were compared with respect to: student retention; time to graduation; matriculation scores, and performance in medical school. The association between matriculation scores and third‐year examination results was determined. Results The average student retention rates for the non‐ADP (1992–2001) and ADP (1991–2000) cohorts were 92% and 70%, respectively. Non‐ADP and ADP students who graduated were compared with respect to four parameters: the mean additional time required to graduate by each group was 0.16 years (95% confidence interval [CI] 0.13–0.18) and 0.38 years (0.27–0.48), respectively. Mean matriculation scores were 44.5 (95% CI 44.4–44.7) and 37.4 (95% CI 37.0–37.7) points, respectively (effect size = 3.2). Mean marks for third‐year courses were 65.0% (95% CI 64.6–65.4) and 58.7% (95% CI 57.7–59.6), respectively (effect size = 1.0). Mean marks for final‐year courses were 68.3% (95% CI 68.1–68.5) and 64.2% (95% CI 63.6–64.7), respectively; the effect size remained constant at 1.2. Third‐year marks for non‐ADP and ADP students, respectively, showed moderate (11%) and low (3%) association with matriculation scores. Conclusions Although the retention of ADP students was lower than that of non‐ADP students, the ADP enabled those who graduated to overcome the effects of under‐resourced schooling and to perform well in final‐year examinations.     

Selected medical students achieve better than lottery-admitted students during clerkships

Medical Education 2011: 45 : 1032–1040 Objectives A recent controlled study by our group showed that the dropout rate in the first 2 years of study of medical students selected for entry by the assessment of a combination of non‐cognitive and cognitive abilities was 2.6 times lower than that of a control group of students admitted by lottery. The aim of the present study was to compare the performance of these two groups in the clinical phase. Methods A prospective cohort study was performed to compare the performance of 389 medical students admitted by selection with that of 938 students admitted by weighted lottery between 2001 and 2004. Follow‐up of these cohorts lasted 5.5–8.5 years. The main outcome measures were the mean grade obtained on the first five discipline‐specific clerkships by all cohorts and the mean grade achieved on all 10 clerkships by the cohorts of 2001 and 2002. Results Selected students obtained a significantly higher mean grade during their first five clerkships than lottery‐admitted students (mean ± standard error [SE] 7.95 ± 0.03, 95% confidence interval [CI] 7.90–8.00 versus mean ± SE 7.84 ± 0.02, 95% CI 7.81–7.87; p < 0.001). This difference reflected the fact that selected students achieved a grade of ≥ 8.0 1.5 times more often than lottery‐admitted students. An analysis of all mean grades awarded on 10 clerkships revealed the same results. Moreover, the longer follow‐up period over the clerkships showed that the relative risk for dropout was twice as low in the selected student group as in the lottery‐admitted student group. Conclusions The selected group received significantly higher mean grades on their first five clerkships, which could not be attributed to factors other than the selection procedure. Although the risk for dropout before the clinical phase increased somewhat in both groups, the actual dropout rate proved to be twice as low in the selected group.     

The risk factors for hospital re‐admission in medical patients in Singapore

Unplanned hospital re‐admissions are common, expensive and often unpreventable in the community. The study aimed to identify risk factors associated with unplanned hospital re‐admission in Singapore. In a cross‐sectional survey, 1509 patients admitted to the medical wards of a large acute hospital in Singapore during 2010 were recruited (78.8% response rate), data being collected using a structured questionnaire based on the Andersen behavioural model underlying healthcare use. The dependent variable was re‐admission within 28 days, with independent variables in the four areas of predisposing characteristics, needs, enabling resources and health behaviour. Hierarchical logistic regression was used to evaluate the risk factors associated with unplanned hospital re‐admission. There were 222 inpatients re‐admitted (14.7%) within 28 days and the final model showed that patients who were unemployed (OR = 1.5; 95% CI = 1.1–2.1) and had chronic obstructive pulmonary disease (OR = 2.0; 95% CI = 1.1–3.7) with abnormal respiratory patterns (OR = 1.6; 95% CI = 1.1–2.2) were more likely to be re‐admitted. Less likely to be re‐admitted were patients doing regular daily activities (OR = 0.7; 95% CI = 0.5–0.9), those assisted by a social worker (OR = 0.3; 95% CI = 0.2–0.6), those referred to other health professionals when sick (OR = 0.6; 95% CI = 0.4–0.7) and those who had received health education programmes before discharge in the previous admission (OR = 0.7; 95% CI = 0.4–0.9). Unplanned re‐admissions are a concern to healthcare providers because this suggests that patients are discharged with unresolved problems that reflect ineffective care in hospital. This study provides evidence to prompt more effective discharge educational care programmes that incorporate patients' enabling and need outcomes, thereby reducing re‐admission rates. Community‐based healthcare should play an important role in reducing patients' re‐admission rates.     

Analysis of small sample size studies using nonparametric bootstrap test with pooled resampling method

Experimental studies in biomedical research frequently pose analytical problems related to small sample size. In such studies, there are conflicting findings regarding the choice of parametric and nonparametric analysis, especially with non‐normal data. In such instances, some methodologists questioned the validity of parametric tests and suggested nonparametric tests. In contrast, other methodologists found nonparametric tests to be too conservative and less powerful and thus preferred using parametric tests. Some researchers have recommended using a bootstrap test; however, this method also has small sample size limitation. We used a pooled method in nonparametric bootstrap test that may overcome the problem related with small samples in hypothesis testing. The present study compared nonparametric bootstrap test with pooled resampling method corresponding to parametric, nonparametric, and permutation tests through extensive simulations under various conditions and using real data examples. The nonparametric pooled bootstrap t‐test provided equal or greater power for comparing two means as compared with unpaired t‐test, Welch t‐test, Wilcoxon rank sum test, and permutation test while maintaining type I error probability for any conditions except for Cauchy and extreme variable lognormal distributions. In such cases, we suggest using an exact Wilcoxon rank sum test. Nonparametric bootstrap paired t‐test also provided better performance than other alternatives. Nonparametric bootstrap test provided benefit over exact Kruskal–Wallis test. We suggest using nonparametric bootstrap test with pooled resampling method for comparing paired or unpaired means and for validating the one way analysis of variance test results for non‐normal data in small sample size studies. Copyright © 2017 John Wiley & Sons, Ltd.     

Malnutrition at Hospital Admission—Contributors and Effect on Length of Stay

Background: In hospitals, length of stay (LOS) is a priority but it may be prolonged by malnutrition. This study seeks to determine the contributors to malnutrition at admission and evaluate its effect on LOS. Materials and Methods: This is a prospective cohort study conducted in 18 Canadian hospitals from July 2010 to February 2013 in patients ≥ 18 years admitted for ≥ 2 days. Excluded were those admitted directly to the intensive care unit; obstetric, psychiatry, or palliative wards; or medical day units. At admission, the main nutrition evaluation was subjective global assessment (SGA). Body mass index (BMI) and handgrip strength (HGS) were also performed to assess other aspects of nutrition. Additional information was collected from patients and charts review during hospitalization. Results: One thousand fifteen patients were enrolled: based on SGA, 45% (95% confidence interval [CI], 42%–48%) were malnourished, and based on BMI, 32% (95% CI, 29%–35%) were obese. Independent contributors to malnutrition at admission were Charlson comorbidity index > 2, having 3 diagnostic categories, relying on adult children for grocery shopping, and living alone. The median (range) LOS was 6 (1–117) days. After controlling for demographic, socioeconomic, and disease‐related factors and treatment, malnutrition at admission was independently associated with prolonged LOS (hazard ratio, 0.73; 95% CI, 0.62–0.86). Other nutrition‐related factors associated with prolonged LOS were lower HGS at admission, receiving nutrition support, and food intake < 50%. Obesity was not a predictor. Conclusion: Malnutrition at admission is prevalent and associated with prolonged LOS. Complex disease and age‐related social factors are contributors.     

Task-specific practice of dressing tasks in a hospital setting improved dressing performance post-stroke: a feasibility study

Background: Practise of personal activities of daily living, including dressing improves outcomes for people living at home after a stroke. Less is known about dressing outcomes for hospital inpatients. Aim: This study aimed to investigate the feasibility and outcomes of a group‐based, task‐specific dressing retraining programme for inpatients post‐stroke. Methods: A pre‐post single group study design was used. Retrospective data were collected for stroke inpatients admitted to one hospital between 2007 and 2009. Participants attended a one‐hour dressing group twice weekly during admission, supervised by occupational therapists. Each participant had one or more dressing goals. Scores on the Functional Independence Measure (FIM) upper and lower body dressing items were compared at baseline and at discharge. Results: Of 119 participants who received group‐based training, a mean improvement was found of 2.2 FIM points (95% CI 1.9–2.5, P = 0.0001) for upper body dressing (range 0–7), 2.7 FIM points (95% CI 2.3–3.1, P = 0.0001) for lower body dressing (range 0–7) and 5.2 FIM points (95% CI 4.5–6.0, P = 0.0001) for total dressing scores (range 0–14). Of 242 goals recorded, 48% focussed on shirt/upper body dressing, 35% on pants/shorts, 11% on socks and shoes and 13% involved buttons/fastenings. Conclusions: Task‐specific practice of dressing tasks in a group setting was feasible and made clinically significant differences to dressing performance during inpatient rehabilitation. More rigorous methods of investigation are required in future to minimise selection, measurement and intervention biases.     

Faking good: self-enhancement in medical school applicants

Medical Education 2012: 46 : 485–490 Objectives The problem of dissimulation by applicants when self‐report tests of personality are used for job selection has received considerable attention in non‐medical contexts. Personality testing is not yet widely used in medical student selection, but this may change in the light of recent research demonstrating significant relationships between personality and performance in medical school. This study therefore aimed to assess the extent of self‐enhancement in a sample of medical school applicants. Methods A within‐subjects design compared personality test scores collected in 2007 for 83 newly enrolled medical students with scores for the same students obtained on the same personality test administered during the selection process 4 months previously. Five factors of personality were measured using the International Personality Item Pool and mean differences in scores were assessed using paired t‐tests. Results At the time of selection, the personality scores of successful applicants were similar to those of candidates who were not accepted (n = 271). Once selected, the medical students achieved significantly lower scores on four of the five personality factors (conscientiousness, extroversion, openness to experience, agreeableness) and higher scores on the fifth factor (neuroticism). Of the selected students, 62.7% appeared to have ‘faked good’ on at least one of the five factors measured. Conclusions Applicants to medical school are likely to dissimulate when completing self‐report tests of personality used for selection. The authors review the evidence as to whether such dissimulation reduces construct and predictive validity and summarise methods used to reduce self‐enhancement in applicant samples.     

Multivariate non‐parametric methods for Mann–Whitney statistics to analyse cross‐over studies with two treatment sequences

A non‐parametric strategy for the analysis of ordinal data from cross‐over studies with two treatment sequences and d(⩾2) periods is examined through Mann–Whitney rank measures of association. For each period, these statistics estimate the probability of larger response for a randomly selected patient in one group relative to a randomly selected patient in the other group. Such estimates are as well formed for comparisons between groups for u pairs of periods with the same treatment. Methods for U‐statistics are used to produce a consistent estimate of the covariance matrix for the (d+u) Mann–Whitney estimates. The effects of periods and treatments on the respective Mann–Whitney estimates are evaluated through linear (or log‐linear) models. For estimation of the parameters in these models, a modified weighted least squares method is applied through a (2d−1)⩽(d+u) dimensional basis which effectively addresses potentially near singularities in the estimated covariance matrix of the Mann–Whitney estimates. The proposed methods are applicable to response variables with an interval or an ordered categorical scale. Their scope additionally has capabilities for controlling strata in the design of a cross‐over study or concomitant variables for which covariance adjustment is of interest for reduction of variance. Applications of the methods are illustrated through three cross‐over studies with different specifications for the two sequences of two treatments during two to four periods. Copyright © 1999 John Wiley & Sons, Ltd.     

Comparison of UMAT scores and GPA in prediction of performance in medical school: a national study

Medical Education 2012: 46 : 163–171 Context Medical schools continue to seek robust ways to select students with the greatest aptitude for medical education, training and practice. Tests of general cognition are used in combination with markers of prior academic achievement and other tools, although their predictive validity is unknown. This study compared the predictive validity of the Undergraduate Medicine and Health Sciences Admission Test (UMAT), the admission grade point average (GPA), and a combination of both, on outcomes in all years of two medical programmes. Methods Subjects were students (n = 1346) selected since 2003 using UMAT scores and attending either of New Zealand’s two medical schools. Regression models incorporated demographic data, UMAT scores, admission GPA and performance on routine assessments. Results Despite the different weightings of UMAT used in selection at the two institutions and minor variations in student demographics and programmes, results across institutions were similar. The net predictive power of admission GPA was highest for outcomes in Years 2 and 5 of the 6‐year programme, accounting for 17–35% of the variance; UMAT score accounted for < 10%. The highest predictive power of the UMAT score was 9.9% for a Year 5 written examination. Combining UMAT score with admission GPA improved predictive power slightly across all outcomes. Neither UMAT score nor admission GPA predicted outcomes in the final trainee intern year well, although grading bands for this year were broad and numbers smaller. Conclusions The ability of the general cognitive test UMAT to predict outcomes in major assessments within medical programmes is relatively minor in comparison with that of the admission GPA, but the UMAT score adds a small amount of predictive power when it is used in combination with the GPA. However, UMAT scores may predict outcomes not studied here, which underscores the need for further validation studies in a range of settings.     

A repurposed tool: the Programme Evaluation SOAP Note

Medical Education 2010: 44 : 298–305 Context Doctors have used the subjective–objective–assessment–plan (SOAP) note format to organise data about patient problems and create plans to address each of them. We retooled this into the ‘Programme Evaluation SOAP Note’, which serves to broaden the clinician faculty member’s perspective on programme evaluation to include the curriculum and the system, as well as students. Methods The SOAP Note was chosen as the method for data recording because of its familiarity to clinician‐educators and its strengths as a representation of a clinical problem‐solving process with elements analogous to educational programme evaluation. We pilot‐tested the Programme Evaluation SOAP Note to organise faculty members' interpretations of integrated student performances during the Year 3 patient care skills objective structured clinical examination (OSCE). Results Eight community clerkship directors and lead clerkship faculty members participated as observers in the 2007 gateway examination and completed the Programme Evaluation SOAP Note. Problems with the curriculum and system far outnumbered problems identified with students. Conclusions Using the Programme Evaluation SOAP Note, clerkship leaders developed expanded lists of ‘differential diagnoses’ that could explain possible learner performance inadequacies in terms of system, curriculum and learner problems. This has informed programme improvement efforts currently underway. We plan to continue using the Programme Evaluation SOAP Note for ongoing programme improvement.     

Cross‐institutional progress testing: feasibility and value to a new medical school

Medical Education 2010: 44 : 184–186 Objectives This study aimed to examine the feasibility of using a progress test to compare the rate of knowledge acquisition among students at a new medical school with that of students at a comparable but long‐established school. Methods As part of an ongoing strategy, we administered the McMaster Personal Progress Index (PPI) on four occasions to the first two cohorts of students enrolled in the graduate‐entry medical programme at the University of Limerick. We compared mean PPI scores for students at comparable stages in their courses at both schools. Results To date, the rate of knowledge acquisition is similar in students at both schools. Conclusions Inter‐institutional and international collaboration in progress testing is feasible and provides a useful quality assurance tool which can be used by new schools to reassure students, faculty members and accrediting bodies.     

Recent health care transitions and emergency department use by chronic long term care residents: a population-based cohort study

ObjectivesLong term care (LTC) residents commonly experience transitions between health care settings that can have important health consequences. The objective of this study was to quantify the effect of recent transitions on the risk of emergency department (ED) transfer among chronic LTC residents. Two types of transitions were considered: admission into LTC and discharge from hospital.DesignRetrospective cohort study using linked administrative data from Ontario, Canada.ParticipantsAll chronic LTC residents in Ontario older than 66 years on the date of the 2005 provincial LTC facility census.MeasurementsUsing facility census date as baseline, admission to LTC was defined as the number of days between LTC admission and baseline. Residents were categorized as one of: newly admitted (≤30 days), shorter-stay (31–90 days), or longer-stay (≥91 days). Within each group, residents were further subdivided based on having had a recent discharge from hospital. The first ED visit for each resident during the 6-month follow-up was counted, as were death and other competing risks. The cumulative incidence of ED transfer for each group was estimated and logistic regression was used to test whether differences between groups persisted after controlling for resident characteristics.ResultsOf the 64,589 residents, 3.0% were newly admitted, 4.9% were shorter-stay, and 92.1% were longer-stay. The 6-month cumulative incidences of ED transfers were 35.0% for newly admitted, 30.7% for shorter-stay, and 22.0% for longer-stay. The odds of an ED transfer were higher for newly admitted and shorter-stay residents relative to longer-stay residents, even after adjustment for resident characteristics (adjusted odds ratio, 95% confidence interval 1.9, 1.7–2.1; and 1.5, 1.4–1.7, respectively). Regardless of time since LTC admission, residents with a recent discharge from hospital had a cumulative incidence of nearly 40% and an increase in the odds of ED transfer of at least 50% compared with those who had not been in hospital.ConclusionsHealth care transitions, especially those from hospital, are associated with an increase in ED transfers among older chronic LTC residents. These findings highlight the need for a stronger focus on transitional care, especially posthospital care, for LTC residents.     

Comparison of nutritional risk screening tools in patients on admission to hospital

Background and aims Undernutrition has been frequently reported in patients on admission to hospital. Because this is not always detected promptly, screening for nutritional risk on admission has been widely advocated. Although there is no universally accepted ‘gold standard’ for defining undernutrition, the definition used by McWhirter, J.P. & Pennington, C.R. [(1994) Br. Med. J. 308 , 945] has been widely used by clinical nutrition specialists. This study aimed to compare the efficacy of two frequently used nutritional risk screening tools in detecting undernutrition according to this definition. Methods Both the Nutrition Risk Index [Veterans Affairs Total Parenteral Nutrition Co‐operative Study Group (1991) N. Engl. J. Med. 325 , 525] and the Nutrition Risk Score [Reilly H.M. et al. (1995) Clin. Nutr. 14 , 269] were used to screen for undernutrition in 359 admissions to two acute teaching hospitals in Dublin. Undernutrition was defined as a Body Mass Index below 20 kg m^?2 and a triceps skinfold thickness or mid‐arm muscle circumference below the 15th percentile. Comparison of stratification of nutritional risk by the two screening tools was carried out. Results Both screening tools identified over 40% (Nutrition Risk Index, 44%; Nutrition Risk Score, 46%) of all patients assessed as at nutritional risk on admission. However, one‐third of the undernourished patients were classified as at no nutrition risk by the Nutrition Risk Index, while almost one‐fifth of those undernourished were classified as at low risk by the Nutrition Risk Score. The degree of nutritional risk differed with the screening tool used, the Nutrition Risk Score classifying 29% of all patients as high risk while the Nutrition Risk Index classified only 5% as in the high risk category. Conclusions Although a large proportion of patients on admission were classified as being at nutritional risk, the degree of risk was significantly different depending on the screening tool used. Both nutritional risk screening tools evaluated in this study failed to recognize many cases of undernutrition. Evaluation of the efficacy of nutritional screening tools should be promoted as seriously as the development of such tools.     

At-risk medical students: implications of students' voice for the theory and practice of remediation

Medical Education 2010: 44 : 1038–1047 Objectives A mandatory remedial programme for students who repeat their first semester at medical school has resulted in large gains in academic performance and greatly reduced attrition. Here, we explore the students’ views of this in order to clarify understanding of optimal remediation practice. Methods Using a mixed‐methods approach, quantitative and qualitative data were gathered from student surveys (n = 333) and three in‐depth focus groups. Results were analysed for emergent themes. Results Remedial programmes for at‐risk medical students should be mandatory, but should respect students’ identity as repeaters. Attitude and motivation are key, and working in stable groups provides essential emotional and cognitive support. The learning environment needs to foster changes in students’ ways of thinking and their development as flexible, reflective learners. These endeavours require support from honest teachers with rigorous expectations and good facilitation skills. Conclusions Successful remediation needs to challenge students’ conceptions of learning, works best in groups with skilled facilitators, and must take into account a blend of cognitive and affective factors and the complex interplay between learner and environment. Given a carefully designed programme, at‐risk medical students can learn to make effective and lasting changes to their approach to study, and their views of learning can come to converge with influential ideas in the education literature.     

Hospital admission patterns in adult patients with skin and soft tissue infections: Identification of potentially avoidable hospital admissions through a retrospective database analysis

Background: Despite the substantial hospitalization costs associated with the management of patients with skin and soft tissue infections (SSTIs) in the inpatient setting, there is limited guidance on patients who should be managed in the hospital relative to the outpatient setting. Studies have demonstrated that SSTI patients without major complications or comorbidities can be successfully managed in the outpatient setting. However, there are limited data on current hospital admission patterns for patients with SSTI. Objectives: Given this literature gap, this study described the current hospital admission patterns among adult patients with SSTI using data from a US hospital research database. Methods: To determine the subset of hospitalized SSTI patients who could likely be managed in the outpatient setting (potentially avoidable hospital admissions), the distribution of hospital admissions was categorized by infection severity and Charlson Comorbidity Index (CCI) score. Results: During the study observational period, there were 610,867 medical encounters across 520 hospitals. Of the 610,867, 125,743 (20.6%) were treated as inpatients. Nearly all patients with life-threatening conditions or systemic symptoms or a CCI score of 2 or greater were admitted. Among those with no life-threatening conditions and no systemic symptoms, admission rates exceeded 10 and 30% for patients with a CCI score of zero and 1, respectively. While the admissions rates for these patient populations were low, they accounted for nearly 60% of all admissions (75,255 of 125,743 hospital admissions). On average, patients with CCI score of zero or 1, independent of the presence of systemic symptoms, were treated in the hospital for about 4 days, costing $6000–$7000 on average. Conclusions: Given the cost associated with the management of patients with SSTIs in the inpatient setting, the findings highlight the critical need for healthcare systems to develop well-defined criteria for hospital admission based on presence of comorbid conditions and infection severity.     

Factors associated with return‐to‐work and health outcomes among survivors of road crashes in Victoria

Objective: To explore the relationships between injury, disability, work role and return‐to‐work outcomes following admission to hospital as a consequence of injury sustained in a road crash. Design and setting: Prospective cohort study of patients admitted to an adult trauma centre and two metropolitan teaching hospitals in Victoria, Australia. Participants were interviewed in hospital, 2.5 and eight months post‐discharge. Participants: Participants were 60 employed and healthy adults aged 18 to 59 years admitted to hospital in the period February 2004 to March 2005. Results: Despite differences in health between the lower extremity fracture and non‐fracture groups eight months post‐crash the proportions having returned to work was approximately 90%. Of those returning to work, 44% did so in a different role. After adjustment for baseline parameters, lower extremity injuries were associated with a slower rate of return to work (HR: 0.31; 95%CI: 0.16–0.58) as was holding a manual occupation (HR: 0.16; 95%CI: 0.09–0.57). There were marked differences in physical health between and within the injury groups at both follow‐up periods. Conclusions: These results demonstrate that both injury type and severity and the nature of ones occupation have a considerable influence on the rate and pattern of return to work following injury. Further, persisting disability has a direct influence on the likelihood of returning to work. The implications of these findings and the types of data required to measure outcome post‐injury are discussed.