An information technology course in the medical curriculum

This paper concerns the information technology course now running in year 1 of the undergraduate curriculum of the medical school of Leeds University. The background and objectives of the course are described, and the course content is outlined in terms of knowledge and practical skills. By the end of the course, 95% of students could successfully accomplish 95% of the skill tasks taught. As regards attitudes to IT, independent studies comparing two randomly selected groups suggested students who had taken the course (a) used IT more frequently, and (b) viewed IT more favourably than their counterparts.     

Teaching the teachers — a needs assessment of tutors for a new clinical skills course

There is an increasing trend in undergraduate education towards teaching clinical skills from a community base. A new clinical curriculum was introduced in Newcastle upon Tyne in 1995, beginning with an integrated clinical skills course. Although the attitudes and views of general practitioners (GPs) towards community-based clinical teaching have previously been reported, their perceived training needs have not been formally identified. The aims of this study were to identify the competencies needed by GPs for community-based clinical skills teaching, to compare and contrast these needs with their hospital colleagues, and to use the results to develop a teaching programme for the clinical tutors involved in the new course. In order of priority, the GPs and hospital tutors expressed similar needs: small-group teaching skills, assessing student needs, giving effective feedback and assessment of student performance, with a preference for the teaching to be organized within local teaching units. Most GPs and hospital tutors (73 and 69%, respectively) requested a distance-learning pack to complement the teaching. General practitioners rated resources for improving their individual clinical skills more highly than their hospital colleagues: for example, videotapes demonstrating examination techniques. Forty-six per cent of GP tutors had received some formal training in teaching methods compared to 29% of hospital tutors. The implications of the results for developing a 'Teaching the Teachers' course for clinical tutors are discussed.     

A study of pre-registration house officers' clinical skills

BACKGROUND: Little is known about the ability of pre-registration house officers (PRHOs) to perform basic clinical skills just prior to entering the medical register. OBJECTIVES: To find out whether PRHOs have deficiencies in basic clinical skills and to determine if the PRHOs themselves or their consultants are aware of them. METHOD: All 40 PRHOs at the Chelsea and Westminster and Whittington Hospitals were invited to undertake a 17 station OSCE of basic clinical skills. Each station was marked by one examiner completing an overall global score after completing an itemised checklist. An adequate station performance was the acquisition of a pass/borderline pass grade. Prior to the OSCE, a questionnaire was given to each PRHO asking them to rate their own abilities (on a 5-point scale) in the skills tested. A similar questionnaire was sent to the educational supervisors of each PRHO asking them to rate their house officer's ability in each of the same skills. RESULTS: Twenty-two PRHOs participated. Each PRHO failed to perform adequately a mean of 2.4 OSCE stations (SD 1.8, range 1-8). There were no significant correlations between OSCE performance and either self- or educational supervisor ratings. The supervisor felt unable to give an opinion on PRHO abilities in 18% of the skills assessed. DISCUSSION: This study suggests that PRHOs may have deficiencies in basic clinical skills at the time they enter the medical register. Neither the PRHOs themselves nor their consultants identified these deficiencies. A large regional study with sufficient power is required to explore the generalizability of these concerns in more detail.     

Evaluating primary care as a base for medical education: the report of the Cambridge Community-based Clinical Course

BACKGROUND: Medical students receive increasing amounts of their clinical education in a primary care setting. The educational possibilities of such attachments are still being explored. AIM: To report the evaluation of a small, radical innovation to provide students with a long-term community attachment which integrated with hospital-based education. METHOD: Between 1993 and 1998, 13 medical students completed 15-month attachments with a single general practice in England. The course offered them experience in the major clinical specialties throughout this period. Students were exposed to specialist as well as generalist education in the context of patients with whom they could establish a continuing relationship. The innovation was evaluated by its feasibility, by students' examination results, by analysis of clinical experience, through formal student feedback and by cost. RESULTS: The course was practicable in a particular setting with academic leadership. The students all passed their exams. They had wide, appropriate clinical experience even though the attachment was to a single practice. When they returned to the hospital environment, students did not feel themselves at a disadvantage compared with traditional students. The costs of the course are controversial: placement costs were higher than in the hospital, but those for facilities were lower. CONCLUSION: It is possible to run a course like this successfully. It remains the most radical attempt to share clinical education in the UK between primary and secondary/tertiary care. Further research is required into providing long-term clinical attachments in NHS primary care settings.     

Meeting the needs of future physicians: a core curriculum initiative for postgraduate medical education at a Canadian university

In addition to possessing medical expertise, contemporary physicians are expected to be skilled communicators, critical consumers and users of medical research, teachers, collaborators, health care advocates, and managers. A core curriculum is a common set of learning experiences designed to help prepare physicians for these complex roles. PURPOSE: This article describes the design and implementation of one core curriculum, summarizes the feedback received from residents, and shares some of the lessons we are learning as we use feedback to develop our programme. METHOD: The core curriculum described was implemented at a Canadian university which offers 56 residency programmes with a total enrollment of approximately 360 students. The curriculum consisted of 30 sessions organized around four themes: biostatistics and epidemiology; communications and teaching skills; healthcare management, and ethical, medicolegal and lifestyle issues. Each session in the Core Curriculum was evaluated by residents with respect to the timing, quality, and value of the learning experience. In addition, residents participated in focus group discussions of their Core Curriculum experiences. RESULTS: Key findings related to the characteristics of effective core curriculum learning experiences and to the barriers to implementing a core curriculum across programmes. Of particular salience were findings related to explicit issues of attendance and the diverse needs of learners and programmes, and to more implicit issues of communication and managing change. The specific content and format of the Core Curriculum and the results of the evaluation process will be of interest to others considering a core curriculum for postgraduate medical programmes.     

Staff development of tutor skills for problem-based learning

The medical faculty of the University of Liverpool is undergoing a major curriculum reform from a traditional course to a student-centred curriculum. To help facilitate the change, staff have been supported by a staff development programme. This paper describes the initial workshop in a programme introducing problem-based learning for over 300 participants, and its evaluation.     

What is core? Guidelines for the core curriculum in paediatrics

A key point that the UK General Medical Council addressed in its recommendations on the undergraduate medical education was the concept of `core curriculum' (General Medical Council 1993). Although enthusiastic for the idea of reducing factual overload, many medical teachers found themselves facing the task of how to define what a core curriculum is, what should be included and why. Predictably, our initial response is to include common and important topics, but how common is common, and how does one determine the relative importance of topics? We do not claim to have unravelled all the ambiguities surrounding the subject nor to have resolved all the controversies that are inevitably encountered. We hope, however, to describe some of the principles that governed our approach and put forward some guidelines, that may contribute to the debate.     

Context in medical education: the informal ethics curriculum

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the ' informal curriculum ' that is so central to the moral development of medical students and residents.
A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a ' practical ethics of conduct ' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.     

The impact of formal instruction in clinical examination skills on medical student performance -- the example of peripheral nervous system examination

BACKGROUND: Peripheral nervous system examination is an essential part of the full medical clerking of a patient. We have investigated the effectiveness of formal instruction in peripheral nervous system examination compared to the traditional bedside ward teaching that our students usually receive. METHOD: We instructed an unselected group of 22 medical students in peripheral nervous system examination in a clinical skills centre and evaluated them with a 12 item marking schedule before and after instruction. The performance of this group was then compared to the rest of their year (220 students) in an end of year OSCE, which included a neurology station assessing sensory examination of the lower limbs. RESULTS: Students formally instructed in neurology significantly improved their scores after instruction and scored 15% higher marks (90% vs. 75%) than the rest of their year in the end of year neurology OSCE station 2 months later (P < 0.01, Mann Whitney U-test). They did not perform significantly better in the OSCE overall. CONCLUSIONS: Formal instruction in neurological examination resulted in a significant increase in the end of year neurology OSCE station score compared to traditional heterogeneous teaching methods.     

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.     

Health promotion in the medical curriculum

It has been argued that health promotion should be included in the medical curriculum, if medical education is to match the needs and health goals of communities. In spite of the medical profession's awareness of the importance of health promotion, few universities in the UK have introduced a substantive course on the subject. This paper describes the teaching of health promotion in Nottingham Medical School. It identifies the aims and objectives of the course which are amongst others to develop an understanding of: the factors which influence the perception and experience of health and illness; the concepts of health promotion and health education; the scientific basis of health promotion; the relative effectiveness of approaches used; the measurement of health status and health behaviour; and health policy and planning. An innovative element of the teaching involves a community project which gives students experience of health promotion in practice. Evaluation of the impact of the course suggests that students perceive it to be interesting, stimulating and enjoyable, whilst examination and continuous assessment indicate that it has also influenced students' knowledge and understanding of the subject.     

The curriculum of communication skills teaching at Maastricht Medical School

In the Skillslab at Maastricht Medical School students are prepared for their first encounters with patients. Students can focus on individual skills, separately mastering each skill in a controlled systematic manner. With this foundation students are better equipped to face the complex intellectual and emotional demands of real patients. A large proportion of training concerns communication skills. Features of Skillslab communication skills training programme are: (1) its continuity (once every 2 weeks, from year 1 to year 6); (2) a gradual increase of complexity in skills (basic interview skills, phases of interviews, entire interviews, problem patients); (3) a gradual increase of complexity in practice situations (apparatus, role-playing, simulated patients, real patients). Evaluation shows students' and teachers' satisfaction with the programme. Comparison with conditions required for interpersonal skills training shows that these are fully met. However, there are drawbacks, which are described.     

The lessons of deafness: deafness awareness and communication skills training with medical students

This paper describes a 1-day course on deafness awareness and communication skills with fourth-year medical undergraduates and summarizes their evaluation of the course. Deaf people commonly experience major communication difficulties with doctors. This course gives students an awareness of deafness (and of the insights deaf people can give to an understanding of communication)--the lessons of deafness--and challenges some critical assumptions in medical practice. Students are given personal experience of deafness and of the consequent powerlessness and loss of self-confidence, while also learning new communication skills which they then apply in a role-play consultation with a deaf patient. Systematic evaluation has been built into the programme and student opinion has been unanimously enthusiastic.     

Pre-registration rotations into general practice: the concerns of pre-registration house officers and the views of hospital consultants

AIMS: To explore the concerns of pre-registration house officers (PRHOs) and the views of hospital consultants in relation to pre-registration rotations with a general practice component. METHOD: As part of a larger qualitative study evaluating how a group of 24 PRHOs learn in hospital and primary care settings, face-to-face semistructured interviews were conducted with the PRHOs, and semistructured telephone interviews with the PRHOs' educational supervisors were carried out. RESULTS: The interviews with the PRHOs highlighted their concerns about how consultants might view PRHO rotations into general practice. However, the majority of consultants interviewed recognized and valued specific aspects of the experience to be gained by PRHOs in general practice, including the relationship between primary and secondary care; communications skills; specific clinical skills, and an understanding of the natural course of illnesses. The experience was seen as valuable for PRHOs considering either a general practice or a hospital career. Of the 17 consultants, 10 were also confident that 4-month placements in surgery and medicine would give PRHOs adequate experience in either specialty, providing the placements were sufficiently busy. CONCLUSIONS: Medical school deans and medical students considering PRHO rotations with a general practice component can be encouraged by the fact that, in this small study, the majority of hospital consultants interviewed valued the specific experience offered by these rotations, and felt that adequate medical and surgical experience could be gained in busy 4-month hospital placements.     

An innovative examination ending the medical curriculum

There has been increasing interest in curriculum innovation in many medical schools. The pedagogic principles for learning and for assessment should be congruent. Changing the curriculum and pedagogic principles for medical education implies that the examinations should also be adapted to the new principles. At the Faculty of Health Sciences, Linköping University, we use a student-oriented programme with problem-based learning, early patient contact, multiprofessional integrated education, and integration between basic science and clinical medicine and between traditional medical subjects. We also encourage the students to adopt a scientific attitude from the very beginning. To assess the students at the conclusion of the medical curriculum, we have developed a new form for the final examination containing measurements of clinical ability based on a videotaped patient consultation, an assessment of the student's performance and presentation of a scientific project, the student's analysis of a published scientific paper and an extensive oral examination based on the students' own scientific papers. Our experience, including results from questionnaires to students and teachers, is that the method is suitable for a final examination and assesses qualities that we previously were not able to assess.     

Smoking history-taking skills: a simple guide to teach medical students

Many doctors rate themselves as ineffective smoking cessation counsellors. It is logical to initiate training efforts with medical students. We incorporated smoking history-taking in the physical diagnosis course at the University of North Carolina at Chapel Hill using a simple method to teach smoking history-taking skills and to assess its effectiveness as an educational intervention. The principal intervention was the distribution of a one-sheet Smoking-History Taking and Counseling Guide, adapted from the American Lung Association's Freedom From Smoking for You and Your Family self-help manual. The second intervention was a single prompt for 50% of the course preceptors. Students' smoking history-taking skills were evaluated in the Objective Structured Clinical Examination (OSCE) at the end of the course. Students who received the guide did significantly better on the OSCE, even after controlling for having discussed taking a smoking history with their preceptors. A simple guide combined with a one-time prompting of preceptors has a positive effect on the acquisition of smoking history-taking skills by the medical students. This strategy may also be useful for teaching and evaluating smoking-cessation counselling skills, for which good smoking history-taking is a necessary basis.     

Integrating human factors into the medical curriculum

Background  The study of human factors is a scientific discipline that deals with the interactions between human beings and the elements of a system. This is important because shortcomings in these areas, if unchecked, can result in adverse outcomes. Research into human factors in industries where safety is paramount has provided the basis of countermeasures against human error. Adverse outcomes in medicine resulting from human error exact a high cost in both patient suffering and financial outlay.
CRM training  One of the approaches used to minimise the effect of human error is to train people in a set of knowledge, skills and attitudes that underpin the domain-specific competencies for that profession. These are referred to as non-technical skills (NTS). In aviation, such an approach has been shown to be both translatable from the training environment to the workplace and effective in reducing adverse outcomes.
Discussion  Medicine has incorporated this style of training, usually centred around simulator-based courses, but as yet in a piecemeal, episodic fashion which relies on participants volunteering to attend courses. Unlike other industries there is no systematic approach to linking the content of this teaching with the more conventional range of topics. As a consequence it is difficult to assess the impact of human factors training in medicine. This is partly because very little work has been done to date in identifying the key non-technical skills required in medicine, and the overall experience of workplace based assessment is limited. Lessons from other high reliability organisations may help to address the main challenges of developing the content, integrating it into the curriculum, reinforcing the concepts in the workplace through staff development and establishing its role in summative assessment.     

Competence of medical students in history taking during the clinical course

Twelve students were selected from each of the three clinical undergraduate years, two from each year interviewing one of six simulated patients. The interviews were video recorded and scored by two clinicians on a rating system involving sixteen criteria. In addition to the expected differences between individual students, when the scores were placed in rank order a pattern of differences between years of study emerged. Students of the third clinical year performed better than those of the first year and both were better than those of the intermediate second year. Junior students displayed more personal concern for the patients, while senior students tended to conduct a more controlled and structured interview.     

One year's experience with a clinical skills resource centre

OBJECTIVES: To describe our experience of teaching clinical skills to first-year medical students in a new problem-based curriculum. DESIGN: Prospective evaluation of clinical skills acquisition using objective measures. SETTING: Students were taught in a purpose-designed clinical skills resource centre in weekly structured sessions. SUBJECTS: All 210 first year medical undergraduates in the first year of a new problem-based and clinically oriented course. RESULTS: Student performance in structured objective examinations improved over 1 year. In all but one of nine matched stations, involving history, examination and procedural skills, improvements were significant. Ninety-three per cent thought that the appropriateness of the skills training course to other course elements was 'good' or 'very good'. CONCLUSIONS: First-year medical students can learn a wide range of clinical skills. Integrated teaching of clinical skills improves satisfaction with undergraduate studies.     

Assessing the ability of medical students to apply evidence in practice: the potential of the OSCE

OBJECTIVES: Critical analysis and application of evidence-based practice are key skills for students to master. Assessment of these skills can be undertaken by written examination. Regardless of how knowledge of the appraisal process may be assessed, written examinations ignore assimilation of that evidence into everyday practice. DESIGN: A combined clinical and communication skills station was used in an objective structured clinical examination where the ability to appraise evidence critically was assessed along with the application of that evidence in managing a common clinical problem. SETTING: University of Liverpool. SUBJECTS: Undergraduate medical students. RESULTS: The results from 156 undergraduate medical students demonstrated that it is possible to assess the application of evidence in practice, both in terms of outcome and patient assessment of the encounter. CONCLUSIONS: Assessment is a powerful tool in promoting learning and adoption of such assessment strategies may help to address concerns surrounding apparent poor effect of critical appraisal training.