Peer-assisted learning: a novel approach to clinical skills learning for medical students

OBJECTIVE: This study aimed to determine whether peer-assisted learning (PAL) can enhance clinical examination skills training. METHODS: Three student trainers studied small-group theory and clinical examination and provided PAL as extra tuition for 86 trainees. Trainees watched an examination video, were videotaped practising the examination and, after constructive feedback, repeated the examination. Responses to PAL were evaluated to attain an overview of trainee and trainer performance using visual analogue and Likert scale analyses. Year-group review was undertaken using questionnaires. RESULTS: Trainees evaluated all aspects of PAL highly, including their post-training confidence in examination skills (mean > 7.7 on a 10-cm scale), indicating that the PAL was effective. Written comments confirmed the students perceived the sessions as well structured and of high quality. Compared with trainees in the first groups, those from later groups gave all parameters similar or higher gradings. Those for interest (P = 0.03) and appropriateness (P = 0.01) were significantly higher, suggesting that trainers may improve their technique with time. Students with previous degrees gave similar or lower gradings than standard entry students, with answers about post-training confidence and recommendation to friends being statistically lower (P < 0.006). Six months later, year-group analysis showed that 90% of trainees rated PAL highly, and 86% wished to become trainers. Of the trainers' year group, 79% perceived that PAL training could improve examination skills. CONCLUSIONS: In the context of clinical skills training, PAL was highly evaluated across many parameters, including confidence after training. Student interest and enthusiasm supports suggestions that PAL could be a useful adjunct to clinical skills training.     

Educational assessment of general practice experience for psychiatric trainees

Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitations of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of 'closed psychological' and 'checking-out' questions. It appears that psychiatric trainees' interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.     

Medical student attitudes to risk taking and self-perceived influence on medical practice

CONTEXT: Little has been published on medical student risk-taking attitudes and behaviours and whether students think these attributes will affect how they treat patients. OBJECTIVES: Our aims were to assess for an association between risk-taking attitudes and behaviours, such as problematic substance use, self-reported risky behaviours, and self-reported accidents, and to test for an association between risk-taking attitudes and student perceptions of the influence of these attitudes on future clinical practice. METHODS: Three consecutive classes of Year 2 medical students (n=315) completed a self-administered, 29-item questionnaire. Risk-taking attitudes were evaluated using a 6-question, risk-taking scale adapted from the Jackson Personality Inventory (JPI). RESULTS: A significant positive correlation was demonstrated between risk-taking attitudes (JPI) and problematic substance use (r=0.34; P<0.01), self-reported risky behaviours (r=0.47; P<0.01), and self-reported accidents (r=0.33; P<0.01). Students who did not think their attitudes toward risk would affect their clinical decision making scored significantly higher on our measure of risk-taking attitudes (t306=-4.60; P<0.01). Students who did not think that their drinking, drug taking or sexual behaviour would affect how they counselled patients on these matters scored significantly higher on our measure of problematic substance use (t307=-2.51; P=0.01). CONCLUSIONS: Although risk-taking attitudes have been associated with significant differences in clinical decision making among doctors, in our sample students with high risk-taking attitudes and behaviours were significantly less likely than their colleagues to think their attitudes would affect their clinical practice. Implications for medical education are discussed.     

Dissection as a modulator of emotional attitudes and reactions of future health professionals

Context  There is ongoing discussion within the medical education community about dissection as an educational strategy and as a professional training tool in technical and emotional skills training.
Objectives  This study aimed to discover the emotional reactions, attitudes and beliefs of new students faced with human cadaver dissection; to evaluate the changes produced in these variables by the exhibition and practice of dissection; to analyse the level of anxiety students feel when faced with death, and to elucidate the possible relationships between these items.
Methods  The study used a sample of 425 students who were first-time enrolees in a human anatomy course. Three new instruments were designed, with items covering emotional reactions (cognitive, physiological and motor reactions), beliefs and attitudes related to what the student expects to experience or has experienced in dissection. Death anxiety was measured using the Death Anxiety Inventory.
Results  As students gained more experience of dissection, their emotional reactions were reduced and their attitudes and beliefs changed. Statistically significant differences in the level of death anxiety emerged, depending on the perceptions students had of their degree of preparation for dissection, and emotional control and deeper thoughts about life and death during dissection.
Discussion  The practice of anatomy allows the student to learn how to face up to and adapt his or her emotional reactions and attitudes; this gives human cadaver dissection great importance as an educational strategy and as a professional training tool in technical and emotional skills training.     

The influence of gender and specialty on reporting of abusive and discriminatory behaviour by medical students, residents and physician teachers

INTRODUCTION: The perception of whether a given behaviour is abusive differs between students and teachers. We speculated that attitudes towards reporting abusive and discriminatory behaviour may vary by specialty as well as by gender. METHODS: We report a cross-sectional survey of incoming medical students, medical students, residents, and teaching faculty at one Canadian medical school. The discrimination and abuse questions were in the following domains: (i) psychological abuse, (ii) sexual abuse, (iii) physical abuse, (iv) gender discrimination, (v) racial discrimination, (vi) disability discrimination, (vii) derogatory remarks regarding homosexuality. The frequency of self-reported witnessed or experienced abusive and discriminatory behaviour was compared by gender, specialty choice and stage of training. RESULTS: The response rates varied by respondent group: 44/56 (79%) of incoming medical students, 177/218 (81%) of medical students, 134/206 (65%) of residents and 215/554 (38%) of physician teachers. The frequency of these behaviours was perceived to be low by both male and female respondents. Abusive and discriminatory behaviour by physician teachers was noted more frequently by residents (P < 0.001) and physician teachers themselves (P < 0.001) compared with incoming medical students. As well, in general, women noted more abusive and discriminatory behaviour by all teachers, compared with men (P < 0. 003). Each response to the abuse/discrimination questions was also modelled as the independent variable using stepwise multiple regression. The area of specialization (surgical versus non-surgical) altered the reporting of abusive and discriminatory behaviour by women. CONCLUSION: We conclude that female surgical residents and medical students undergo a process of acclimatization to the patriarchal surgical culture. As female surgeons become physician teachers they revert to a culture more similar to that of their female non-surgical colleagues. Although a process of deidealization occurs in medical training, these attitudes are not necessarily retained throughout the practising lifetime of physicians as they regain autonomy and more personal control.     

Learning not to take it seriously: junior doctors' accounts of error

Objectives We aimed to investigate experiences of, and responses to, medical error amongst junior doctors and to examine the challenges junior doctors face and the support they receive. Methods We carried out a qualitative study of 38 randomly selected pre‐registration house officers (PRHOs) in 10 hospitals. All 38 had graduated in 2000 or 2001 from a single medical school. Results Errors were common and sometimes serious. In relation to disclosure and learning from error, four main themes emerged: a norm of selective disclosure; the effects of the team; individualised blame and responsibility, and the ‘learning moment’. Trainees reported disclosing errors informally, particularly when teams were seen as supportive, but were reluctant to criticise colleagues. Formal reports and disclosure to patients were very rare. Patient care was compromised when juniors did not access senior help, often when working outside their usual team environment. Lack of cooperation between teams and poor continuity of care also contributed to errors. Learning was maximised when errors were formally discussed and constructive feedback offered. However, both blame and the prioritisation of reassurance over learning and structured feedback appeared to inhibit reflection on the experience of error. Conclusions Junior doctors need help to reflect on their experiences and to recognise where they may have made mistakes, particularly in the contexts of shift‐work and fragmented teams. Formal reporting systems alone will not facilitate learning from error. Juniors require individual clinical supervision from seniors with appropriate training. Such expertise may benefit the whole team and the training environment.     

Teaching and learning about human sexuality in undergraduate medical education

BACKGROUND: Effective management of the doctor's role in relation to human sexuality requires sensitivity and tact, an ability to put patients at ease, use of appropriate language, and therapeutic, non-discriminatory attitudes. However, previous research suggests that medical students and doctors may hold negative attitudes towards homosexuality and some forms of sexual behaviour. Some educational programmes have started to help students develop communication skills for sexual health consultations, but little work has addressed the broader issue of attitudes and values which may underlie behaviour. It is vital that medical students begin early the process of reflection and recognition of how their attitudes and values might influence their care of patients. In this paper we report on a course designed to initiate this process at Leicester-Warwick Medical School (LWMS). COURSE DESCRIPTION: The course utilizes techniques of desensitization, problem-solving and reflection to enable the students to achieve the learning outcomes, which are primarily oriented towards reflection and self-development. It uses a variety of teaching and learning strategies, combining peer learning with self-directed learning, and small-group learning with whole class learning. COURSE EVALUATION: We report observations and a before-and-after questionnaire study of students' views and attitudes. This evaluation suggests that the course is successful in reducing students' anxieties about human sexuality and improving their confidence in developing appropriate skills. CONCLUSIONS: The LWMS course is one model which might be used to begin the process of encouraging medical students to develop ways of appropriately managing their responsibilities in relation to human sexuality.     

Attitudes of Ugandan medical students toward 'straight' and 'modified' ECT

In third world countries, limited resources of anaesthetists and resuscitation facilities mean that electroconvulsive therapy (ECT) is usually given 'straight'(i.e. without anaesthetic and muscle relaxant). This study compared the attitudes of Ugandan medical students towards ECT given straight and ECT administered with muscle relaxant and general anaesthesia (i.e.'modified' ECT). Results confirmed the clinical impression that students regarded straight ECT as an inhumane method of treatment. However, whilst this was a major factor influencing students' preference for modified ECT as a treatment for themselves or for a close friend, it was relatively unimportant in determining their choice of ECT technique for a patient. Convenience of administration was the main criterion applied by students when deciding whether they would prefer to administer straight or modified ECT to a patient. Implications for medical education and the development of professional attitudes are discussed.     

Medical students' perceptions of racial diversity and gender equality

OBJECTIVES: To assess attitudes of medical students toward issues of racial diversity and gender equality and to ascertain changes in these attitudes during the pre-clinical curriculum. METHODS: Attitudes toward multiculturalism and gender equality were assessed using a 43-item questionnaire. The survey was completed by incoming Year 1 students in 2000 and 2001, and was completed again in 2002 by the students who had entered in 2000. Mean scores were analysed at baseline by gender, ethnic group and political affiliation using analysis of variance. The paired scores of the first and follow-up surveys of the 2000 entering class were compared using paired t-tests. RESULTS: Upon entry into medical school, women, minority group students and Democrats scored significantly higher on the cultural sensitivity scale than their comparison groups. No significant changes were seen overall in the matched data. However, minority groups showed a significant increase in scores, while Republicans and white men experienced a non-significant decline. In addition, incoming students judged cultural competency education to be important. The perceived need to increase the numbers of minority group doctors varied by gender, ethnic group and political affiliation. CONCLUSIONS: Among incoming medical students, perceptions of racial diversity and gender equality vary along ethnic, gender and political lines. Additionally, pre-clinical education was associated with increased cultural sensitivity by minority group students, but not by others. These findings demonstrate the continuing need for diversity in medical school and for medical students to recognise and address their personal and group biases.     

Senior medical students' appraisal of CanMEDS competencies

CONTEXT: In 2003 the Dutch Central College of Medical Specialties presented guidelines for the modernisation of all medical specialty training programmes in the Netherlands. These guidelines are based to a large extent on the CanMEDS (Canadian Medical Education Directives for Specialists) 2000 model, which defines 7 roles for medical specialists. This model was adjusted to the Dutch situation. The roles were converted to 7 fields of competency: Medical Performance; Communication; Collaboration; Knowledge and Science; Community Performance; Management, and Professionalism. OBJECTIVE: As changes in postgraduate training will probably be most effective if future trainees recognise their value, we set out to determine how senior medical students rated these fields of competency in terms of their importance. METHODS: We carried out a study at University Medical Centre (UMC) Utrecht, the Netherlands, in which 80 Year 6 medical students answered a questionnaire in which they rated the importance of each of 28 key competencies within the 7 competency fields. RESULTS: Although all key competencies were regarded as important (averages > or = 3.8), Professionalism and Communication scored highest on the student ratings. Management was assessed as least important. CONCLUSIONS: It is interesting that medical students acknowledged the importance of competencies other than those involving medical expertise and performance. It confirms the opinion that educating doctors is currently viewed as much more than providing theoretical and clinical knowledge and skills. The CanMEDS framework is appreciated by Dutch medical students. The fact that all competencies are seen as important adds to their face validity and therefore to their usefulness as a basis for postgraduate training.     

Clinical teachers as role models: perceptions of interns and residents in a Lebanese medical school

OBJECTIVE: To identify the characteristics and learning impact of role models as perceived by interns and residents in an Arabic Middle Eastern country, Lebanon. METHODS: A structured and self-administered questionnaire was sent to the cohort of interns (n = 34) and residents (n = 66) training in a Lebanese university hospital. The questionnaire contained pre-specified items related to professional and personal characteristics of positive and negative role models, as well as to the impact of these models on professional learning and career choices. Responders were asked to recognise and to rank-order the items associated to their identified models. RESULTS: A total of 88 responders (97%) had positive role models and 87 responders (96%) had negative role models in their current training programme. Characteristics identified most frequently and ranked most highly by the trainees were related to clinical skills in positive role models and to inadequate humanistic and collaborative attitudes in negative models. Role modelling had a positive impact on the achievement of clinical skills for 55% of the responders, and on the acquisition of humanistic and collaborative attitudes for 30% of them. Thirty-eight per cent of the trainees were influenced by their role models in the choice of their specialities. Responses were generally comparable between levels of training and between medical and surgical specialities. CONCLUSION: Clinical teachers, practising in a non-occidental cultural and medical learning environment, are considered very frequently as role models by their interns and residents and have a positive impact on their professional learning and career choices. Strategies to reinforce role modelling are needed in Lebanon, in order to pass a broad spectrum of professional values to our students.     

The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students

INTRODUCTION: Much of undergraduate clinical teaching is provided by residents. An earlier study showed the attitude of residents towards teaching to be generally positive. Little is known, however, about attending doctors' views on their own and residents' roles as teachers of medical students. OBJECTIVES: To examine attending doctors' perceptions of the (dis)advantages of resident teaching, their own teaching abilities and the need for a teacher training programme for residents. METHOD: A questionnaire survey of 76 attending doctors was carried out in the Departments of Obstetrics & Gynaecology and Paediatrics at the teaching hospitals of the Universities of Maastricht and Amsterdam, the Netherlands. RESULTS: Attending doctors perceive teaching by residents to be beneficial for students and residents alike. Although they consider themselves to be better suited than residents to teach medical students, they see teaching as an integral part of residency training and feel it should be recognised as such by departments and medical schools. Attending doctors are in favour of a teacher training programme for residents, which should include communication, clinical and teaching skills as well as skills such as time management and (self-) assessment. DISCUSSION: Despite the uneven distribution of participants between the departments, no significant differences were found between departments. It is interesting that attending doctors perceive teacher training as beneficial to residents' teaching skills, but provide more feedback on residents' attitudes than on their teaching. The results show that, in general, attending doctors share residents' views that teaching is an important component of residency and that a teacher training programme for residents is to be recommended.     

Consultant attitudes to undertaking undergraduate teaching duties: perspectives from hospitals serving a large medical school

OBJECTIVE: To explore attitudes among National Health Service consultants responsible for delivering basic clinical teaching to medical students. DESIGN: Postal questionnaire. SUBJECTS AND SETTING: A total of 308 acute hospital trust consultants working in 4 'new' and 4 'established' teaching hospitals in the West Midlands metropolitan area, and involved in the delivery of clinical teaching to Year 3 medical students at the University of Birmingham Medical School during 2002-03. MAIN OUTCOME MEASURE(S): The questionnaire explored contractual requirements, actual teaching commitments and perceptions of medical students' knowledge and attitudes. Responses from doctors and surgeons and from respondents working in established and new teaching hospitals were compared. RESULTS: A total of 249 responses were received (response rate 80.8%). Although many consultants enjoy teaching students, their enjoyment and their ability to deliver high standards of teaching are compromised by time and resource constraints. For many the situation is aggravated by the perceived inappropriate organisation of the clinical teaching curriculum and the inadequate preparation of students for clinical practice. Linking these themes is the overarching perception among teachers that neither service nor educational establishments afford teaching the levels of recognition and reward associated with clinical work or research. CONCLUSION: To overcome barriers to teaching requires more reciprocal links between hospital staff and medical schools, opportunities for consultants to understand and to comment on curricular and timetable developments, and, perhaps most importantly, recognition (in contractual, financial, managerial and personal terms) of the importance of undergraduate teaching in the competing triad of service, research and education.     

Medical students' perceptions of medical malpractice

Despite increasing interest in medical malpractice in the UK, there is very little empirical research on doctors' own concerns. This paper explores first and fifth year medical students' knowledge about malpractice, their attitudes toward litigation and its perceived significance for their future practice.     

Voluntary active euthanasia and doctor-assisted suicide: knowledge and attitudes of Dutch medical students

The objective of the study was to gain insight into the knowledge of and attitudes towards voluntary active euthanasia and doctor-assisted suicide (EEDAS) of Dutch medical students, and to determine whether knowledge and attitudes change after a 1–day informative conference about EDAS. Data were collected by means of two self-administered questionnaires. Questionnaire 1 had to be completed before the start of the conference and questionnaire 2 after the conference. In both questionnaires, students were asked by means of two open-ended questions to define euthanasia and doctor-assisted suicide. They were also asked to indicate which of eight statements met with the requirements for prudent practice. Finally, the students were asked to what extent they agreed or disagreed with each of seven statements about attitudes towards EDAS. To determine if a selection occurred among students who returned both questionnaires, their background characteristics, and knowledge and attitudes towards EDAS were compared with those who returned only the first questionnaire. Forty-seven students returned only the first questionnaire, while both questionnaires were returned by 137 students. No differences were found between students who returned both questionnaires and those who returned only the first questionnaire with regard to age, religion, knowledge of and attitudes towards EDAS. Students' knowledge of the definitions of EDAS and the requirements for prudent practice improved significantly. Students' reactions to the statements on attitudes towards EDAS showed that a large majority had a fairly positive attitude towards EDAS. There was no significant difference before and after the conference. Male students and students with a religion were more opposed to EDAS than female students and students without a religion. The fact that the students' knowledge of EDAS improved after a 1–day conference does not imply sufficient understanding of the issue. Because EDAS is allowed only under strict conditions in the Netherlands, medical students require special training. Only then will they be equipped to deal with requests for EDAS during their future careers.     

Smoking behaviour and attitudes among Australian medical students

Teaching about tobacco and related diseases is essential in the undergraduate medical course in order for students to gain knowledge about smoking and how to intervene with patients who smoke. The objective of the study was to assess students'smoking-related behaviour, knowledge and attitudes towards tobacco, and perceptions of their future role as doctors. Data were collected from two consecutive years of year 1 and year 5 medical students at the University of New South Wales, Sydney. A total of 594 (79%) of students across the 2 years completed the survey: 90% of year 1 students, and 69% of year 5 students. The daily smoking rate among the total medical students was 2.9%: 11.8% in year 1 (2.3% daily, 9.5% occasional) and 13.7% in year 5 (3.3% daily, 10.4% occasional). There were significantly more male than female smokers in year 5 (P < 0.05). The overall smoking rates for males in years 1 and 5 were 12.4% and 19.3%, and the smoking rates for females were 11.2% and 8%. Knowledge about the causal role of tobacco in the development of specific diseases improved significantly from year 1 to year 5 (P < 0.001). Nevertheless, in year 5 there remained a lack of knowledge about the relationship of smoking and some diseases. Fifty-seven per cent of students thought that their current knowledge was sufficient to counsel smokers, with year 5 students (89%) being far more positive than year 1 students (34%) (P < 0.001). Teaching medical students about smoking-related diseases and a patient-centred smoking cessation intervention results in an increase in knowledge, as well as positive perceptions about their future role in intervening with smokers.     

The relationship between pre-registration house officers and their consultants

CONTEXT: Previous studies have drawn attention to the importance of the trainee/trainer relationship in determining job satisfaction and motivation to learn. OBJECTIVES: To study the relationship between pre-registration house officers and their consultants through exploring an interpersonal exchange and the emotional context in which the exchange took place. To consider any association between the type of relationship implied and the trainee's attitude to their career. DESIGN: Postal questionnaire covering a wide range of issues. This study focused on an open question about a significant or interesting exchange, followed by supplementary questions exploring the emotional context of the exchange. SETTING: 336 hospitals throughout the United Kingdom. SUBJECTS: A cohort of doctors were followed from the time of their application to medical school, and studied towards the end of their pre-registration year (n=2456). RESULTS: The response rate to the questionnaire was 58.4%. Responses were categorised as Support and supervision; Unreasonable behaviour; Consultant fallibility; Fair criticism and No exchange. Over half the responses described an interaction that made them feel positive. Trainees particularly appreciated positive feedback, clinical support, teaching, career advice, patronage, or social interaction. The importance of formal appraisal or review sessions in providing the setting for a positive exchange was confirmed. Positive interactions were associated with a positive view of medicine as a career. A minority described an interaction that was negative, involving unreasonable demands, criticism (whether perceived as fair or unfair), humiliation, or sexism. These were associated with a more negative view of medicine as a career, and of themselves as doctors.