Use of scheme-based problem solving: an evaluation of the implementation and utilization of schemes in a clinical presentation curriculum

CONTEXT: The University of Calgary has implemented a new curriculum which is organized according to 120 ways in which patients may present to a physician. Students are taught scheme-based problem solving rather than the more typical hypothetico-deductive or search and scan approach to problem resolution. OBJECTIVE: This study sought to determine the extent to which faculty and students were implementing and utilizing scheme-based problem solving. METHOD: All classes taught within the new clinical presentation curriculum were surveyed at the year end. Participants included four classes of first-year students and three classes of second-year students. Using a 5-point scale, students responded to survey items regarding scheme implementation and utilization. RESULTS: Data were analysed using MANOVA (multivariate analysis of variance) and revealed significant differences among classes in both first- and second-year students. Increments in scheme implementation and utilization by instructors and students were observed, although instructors' utilization of schemes lagged behind that of students. A levelling effect to the benefits of schemes for problem solving was also evident. First-year students reported schemes to be very useful for learning and organizing new information. CONCLUSION: Although it has taken time to implement curriculum change, the student response to schemes has been favourable. Faculty development and further generation of pictorial/spatial representations for all schemes, to ensure that all clinical presentations provide pathways that students can use for both learning and problem solving are recommended. Whether students who utilize schemes are more successful problem solvers is not yet known but will be the subject of study as soon as scheme delivery is predominant.     

What can students learn from studying medicine in literature?

OBJECTIVE: To identify what students can learn from studying medicine and literature as part of a final-year special study module in general practice. METHOD: The project reports and evaluation forms completed by all eight students who had chosen to study medicine and literature as part of their special study module in general practice at Nottingham University Medical School were analysed qualitatively. RESULTS: Students said that they gained a greater understanding of the patient's experience of illness, as a result of the texts they had read. They learned how illness can affect family or friends of the patient and about the psychological impact of physical illness. Most students thought their future care of patients would be influenced by what they had learned. Studying medicine in literature during a clinical attachment allowed students to draw comparisons between literature and their clinical experience. DISCUSSION: This study is based on a small number of students who chose to study medicine in literature. The results may not be generalizable to all medical students and not all students may be receptive to this method of learning. However, we recommend that students who are interested should be given the opportunity to study medicine in literature during their clinical years. This can enable them to reflect on their clinical experience and can provide a more profound understanding of the consequences of illness for the patient and their family.     

Assessment of problem-solving ability

It is recognized that no problem solving can take place without a background knowledge. As the highest marks in PMPs are now being consistently achieved by those candidates who arrive at the correct diagnosis without accumulating excessive information and at the same time avoiding irrelevant or incorrect data the PMP may be measuring efficiency in problem solving ability. This would appear to be substantiated by the fact that reasonable correlations are obtained between each candidate's remarks in problems of widely differing system disease patterns.
The mark allocation is such that the problem solving ability relates to the field of general practice and no detailed specialist knowledge of any particular disease pattern is being measured. In measuring problem solving ability it is advisable to allocate a maximum positive mark for each section, this mark being the total of that awarded for information considered necessary to solve the particular problem. Any negative marks scored must be taken from the maximum positive mark allowed and not from the total positive score obtained, which may be considerably more than the former. In this way the efficient performer is appropriately rewarded whilst the more devious data gatherer is appropriately penalized.     

Clinical problem solving and clinical knowledge

Videotape and simulated patients were used for evaluating third year medical students' performances in solving familiar and unfamiliar clinical problems. To assist the doctor to rate the students' performances by the review of videotapes, criteria were set up for students' behaviours that could be construed as evidence that the students recognized cues obtained by interviewing the patient and the information content of such cues. Criteria for data use by the students were also set. A mean of 90% of the pertinent medical history data was collected by the students. The amount of pertinent historical data collected was found to correlate very closely with student-patient interaction analysis score for the familiar and unfamiliar problems (r = 0.89 and r = 0.92, respectively). Significant differences in mean scores for data generation (P less than 0.001) and for data use (P less than 0.01) were found between those students who solved and those who failed to solve the familiar problem. With the unfamiliar problem a significant difference was found between the mean scores for data generation (P less than 0.01), but not for data use. The implications of these findings in medical education are discussed.     

Simulated patients as a learning resource in the study of reproductive medicine

Simulated patients have been used to foster active learning and problem solving skills in an undergraduate programme of reproductive medicine. These simulators were trained to present a series of clinical problems and were used in a variety of approaches. They served to highlight communication skills and to force attention on the recognition, assessment and management of patient problems.     

Doctors' emotional intelligence and the patient-doctor relationship

Context  Current studies have found limited evidence for an association between doctor emotional intelligence (EI) and the patient−doctor relationship (PDR). This study explored the associations among doctor EI, patient trust and the PDR using multi-source and multi-level approaches.
Methods  A total of 994 outpatients and 39 doctors representing 11 specialties were surveyed.
Results  Doctors' self-rated EI was not significantly correlated with any variables rated by the patients. The nurse-rated PDR and the EI score for the doctor were positively associated with patient trust at a significant level.
Conclusions  Multi-sources for assessment of doctor EI may be more objective and predictive than doctor self-ratings in ascertaining the associations among patient trust, the PDR, and patient satisfaction. Emotional intelligence coaching for doctors and interdisciplinary collaboration among clinicians are needed to optimise the efficient and therapeutic function of the PDR for patients.     

Consulting skills training and medical students' interviewing efficiency

In more traditional medical education, medical students took a patient's medical history by asking a series of sequenced, routine questions, covering presenting medical problem(s); medical history; social and personal history; systems review; and physical examination. Following this process, the student then attempted to derive the patient's medical problems. This inductive problem-solving paradigm may not assist students to prepare for their future interviewing needs, given doctors use a hypothetico-deductive, problem-solving approach when interviewing patients and numerous researchers have developed specialized communication skills training programmes designed to enhance students' interviewing skills. Students given specific consulting skills training have tended to show significantly greater interpersonal effectiveness and improved interview behaviours compared with students who experience traditional patient clerking training. These improvements in interviewing tend to persist over the period of students' medical training. The aim of the present study was to determine whether specialized communication skills training helped students elicit greater quantity and quality of information from patients and if so, whether such information assisted students in improving their diagnostic skills. Videotaped history-taking interviews conducted by students trained in communication skills and untrained (control) students were rated for their interview efficiency. A comparison of ratings given by experimentally naive, independent observers revealed that trained students were more efficient, but took no longer than their control group counterparts to elicit fuller, more relevant information. However, the student groups did not differ in the accuracy or scope of their medical diagnoses. It is argued that students' lack of medical knowledge in this early phase of their clinical training militated against their being able to use their interviewing competence to derive more potentially accurate medical diagnoses.     

Chronic illnesses in Canadian children: what is the effect of illness on academic achievement,and anxiety and emotional disorders?

Background   Survival rates of children with a chronic illness is at an all-time high. Up to 98% of children suffering from a chronic illness, which may have been considered fatal in the past, now reach early adulthood. It is estimated that as many as 30% of school-aged children are affected by a chronic illness. For this population of children, the prevalence of educational and psychological problems is nearly double in comparison with the general population.
Methods   This study investigated the educational and psychological effects of childhood chronic illness among 1512 Canadian children (ages 10–15 years). This was a retrospective analysis using data from the National Longitudinal Survey of Children and Youth, taking a cross-sectional look at the relationships between childhood chronic illnesses, performance on a Mathematics Computation Exercise (MCE) and ratings on an Anxiety and Emotional Disorder (AED) scale.
Results   When AED ratings and educational handicaps were controlled for, children identified with chronic illnesses still had weaker performance on the MCE. Chronic illness did not appear to have a relationship with children's AED ratings. The regression analysis indicated that community type and illness were the strongest predictors of MCE scores.
Conclusions   The core research implications of this study concern measurement issues that need to be addressed in future large-scale studies. Clinical implications of this research concern the need for co-ordinated services between the home, hospital and school settings so that services and programmes focus on the ecology of the child who is ill.     

Learning the skills of flexible sigmoidoscopy – the wider perspective

Background  Nurse-led gastrointestinal endoscopy is a priority clinical area in the UK. Endoscopic procedures are challenging to learn, requiring a combination of technical competence (manipulating a flexible endoscope and interpreting the findings) and interpersonal skills (engaging effectively with a conscious patient who is frequently apprehensive).
This paper explores the potential of an innovative, scenario-based approach which links a simulated patient with a computer-driven virtual reality (VR) training device for flexible sigmoidoscopy. Within this safe yet realistic quasi-clinical environment, learners carry out the procedure while interacting with the 'patient'. Communication skills are assessed by simulated patients, while quantitative performance data relating to the procedure is generated automatically by the VR simulator.
Methods  This pilot study took place within a nurse practitioner endoscopy course. A mixed methodology combined qualitative and quantitative data (observation and interview studies, communication rating scales and a range of computer-generated output measures from the VR simulator) in a multifaceted evaluation.
Results  Seven nurses took part in the study. Participants found the scenarios to be a convincing and powerful learning experience. All experienced high levels of anxiety. Simulated patients identified strengths in participants' communication skills, together with areas for development. Simulator-based practice led to an improvement in objective performance measures.
Discussion  Scenario-based training provides a powerful learning experience, allowing participants to build their technical expertise and apply it within a holistic clinical context without the risk of causing harm.
We used this pilot study as a springboard for discussions over wider implications of procedure-based skills training, locating it within the literature on expertise and situated learning.     

SF-36 as a Predictor of Health States

Background: There are a number of claims that Medical Outcomes Study Short Form 36 (MOS SF-36) mean scores can be used to discriminate between healthy and nonhealthy persons and determine various levels of health.
Objectives: The purpose of this study was to evaluate the ability of the SF-36 to predict whether or not respondents reported health problems.
Methods: We used structural equation modeling (SEM) techniques to evaluate the SF-36 and its ability to discriminate between those who reported health problems or reported physician-determined illness and those who did not in a sample from the 1990 National Survey of Functional Health Status (NHS).
Results: The correlation between physician-determined illness and Physical Health was −.404, resulting in 16.32% shared variance. The correlation between reported health problems and Physical Health was −.360, resulting in 12.96% shared variance. These correlations are markedly lower than those to the eight first-order scales or between Physical and Mental Health ( r = .889). Mental Health could not predict physician-determined illness or reported health problems independent of Physical Health.
Conclusions: The SF-36 is relatively poor at accounting for the health status of respondents. There are significant paths but the variance accounted for in absolute and relative terms is small. Physical Health does a much better job of accounting for general mental health than it does for perceived health problems or physician-determined illness. These findings suggest that the SF-36 may not discriminate well between healthy and nonhealthy groups and that objective measures of health status may be required in conjunction with the use of the SF-36.     

A healing curriculum

CONTEXT: The banner of patient-centredness flies over many academic institutions; however, the practice and teaching of medicine remain oriented to disease. This incongruence is the result of an original Flexnerian dichotomy between the basic and clinical sciences and is maintained by a more recent distinction between disease and illness. One mind-set emphasises basic science and pathology pedagogically, whilst clinical medicine becomes a search for disease. The second introduces the patient as the focal point, underlining the personal and social contexts of illness. RESPONSE AT A CONCEPTUAL LEVEL: We must orient ourselves to a single central theme, namely, the well-being of the individual patient. Doing so does not deny the importance of the scientific understanding of biological function. Indeed, recent advances in genetics may permit a richer view of the individual as a unique product of genetic, developmental and experiential forces. The foregoing provide a coherent framework for a scientifically guided and humanistic medicine, which replaces the false dichotomies that have plagued medical school curricula with a congruent and stereoscopic view of medical education. RESPONSE AT A CURRICULAR LEVEL: We describe an undergraduate programme, entitled 'Physicianship', based on the fundamental premise that healing is the doctor's primary obligation. Explicit training in a specific clinical method, whose cardinal features include observation, attentive listening and clinical reasoning, emphasises the knowledge and skills necessary to effect this theoretical framework. The understanding of illnesses emphasises loss of homeostasis, whereas the physical examination highlights impairments of function. The educational experience is enriched with numerous opportunities for self-reflection.     

How should trainees be taught to open a clinical interview?

Aim  To characterise the opening of secondary care consultations.
Method  We audio-taped 17 first consultations in medical clinics, transcribed them verbatim, and analysed verbal interactions from when the doctor called the patient into the consulting room to when she or he asked clarifying questions.
Results  The interviews did not open with the sequence, reported by previous researchers, of 'doctor's soliciting question, patient's opening statement, interruption by the doctor'. Doctors (1) called the patient to the consultation; (2) greeted them; (3) introduced themselves; (4) made a transition to clinical talk; and (5) framed the consultation. They used a referral letter, the case notes, computer records and their prior knowledge of the patient to help frame the consultation, and did so informally and with humour.
Conclusion  These 5 steps could help trainees create a context for active listening that is less prone to interruption.     

Developing professional clinical skills for practice – the results of a feasibility study using a reflective approach to intimate examination

Objectives  To develop a student-selected component (SSC) for junior medical students, to evaluate the feasibility of incorporating the development of skills in carrying out an intimate examination, whilst developing professional thinking skills using a reflective approach.
Subjects  The student selected component was designed for a maximum of 6 students over a 4-week period in Phase 2 (year 2 and 3) of the undergraduate medical curriculum.
Setting  The Clinical Skills Centre, the Faculty of Medicine Nursing and Dentistry, University of Dundee, Scotland, UK.
Methods  The SSC consisted of a weekly patient clerking from the ward, an analysis of the clinical and communication skills for any intimate examinations the patient would require, and practice using simulators and simulated patients. Students were supported by timed periods of structured reflection, which enabled them to discuss ethical issues and their own professional conduct related to carrying out an intimate examination. The SSC was evaluated on 3 levels; student satisfaction, learning professional thinking using a reflective approach, and observing behaviour change in relation to skill development, using a ward simulation exercise.
Results  The evaluation at the levels of student satisfaction, learning professional thinking and changes in behaviour associated with intimate examination demonstrated that the SSC had been well received by the students, who felt they had improved their skills in intimate examinations in the context of a ward simulation exercise, in parallel with their professional thinking skills.
Conclusion  It is possible to develop the professional thinking of junior medical students at the same time as developing their technical competence in relation to intimate examinations. It may be advantageous to introduce students early to this reflective approach, using simulation to promote the integration of theory with practice.     

Patient simulation for training basic and advanced clinical skills

Introduction  Patient simulators are increasingly used in the education and training of healthcare professionals. This paper describes the history of human patient simulator development, the features of contemporary simulators, the acquisition of basic and advanced clinical skills using patient simulators, and the benefits, cost, limitations and effectiveness of this innovative learning modality.
Simulator development  The development of human patient simulators began in the late 1960s, and accelerated in the late 1980s and early 1990s. Several simulator systems are now professionally manufactured, commercially available, and used at hundreds of medical centres, universities and colleges in the USA and throughout the world. Contemporary patient simulators have many clinical features, and look and respond to interventions with ever-increasing degrees of realism because sophisticated physiological and pharmacological models automatically control many features.
Simulator use in medical education  Simulators are used to teach basic skills, such as respiratory physiology and cardiovascular haemodynamics, and advanced clinical skills, e.g. management of difficult airways, tension pneumothorax, pulmonary embolism and shock.
Benefits, costs and limitations  The simulation laboratory offers distinct educational advantages, especially for learning how to recognise and to treat rare, complex, clinical problems. Costs of simulator-based educational programmes include facility, equipment and personnel. Current limitations include clinical realism of the patient manikin and faculty development.