Major Greenwood's early career and the first departments of medical statistics

Major Greenwood was the foremost medical statistician of the first half of the 20th century in the UK and is often credited with founding the first department of medical statistics at the Lister Institute in London in 1910. Here, we examine in detail his career prior to this appointment, including his association with Karl Pearson. We also examine the remit of the Department of Medical Statistics at the London Hospital of which he was the founding Director in 1908, some 2 years earlier than his appointment at the Lister Institute. Supporting information consisting of further details about Major Greenwood's early career, biographical articles and obituaries for him, and a list of his publications to 1910 by year, is also provided. © 2014 The Authors. Statistics in Medicine published by John Wiley & Sons, Ltd.     

对医师资格考试考生信息管理的思考

医师资格考试是我们国家的一项十分重要的统一考试,报考人员相关信息的准确填报和科学管理是一项十分重要的工作.目前,考生信息管理中存在着信息虚假或错误、不易更新、不易查询等情况,因此,建立一套准确、科学、多方共享的考生信息系统,显得十分迫切和必要.     

The impact of a new educational strategy on acquiring neonatology skills

OVERVIEW: A shortage of staff for teaching neonatology skills to large numbers of students, in small groups and following a new curriculum, necessitated an innovative educational strategy. This entailed the development and implementation of an interactive multimedia program (CD-ROM) to deliver information about skills and to demonstrate them. METHODS: Students had to study a specific skill using the CD-ROM and then practise in the Skills Laboratory, supported by lecturers who provided formative evaluation. OBJECTIVES: The aims of this study were to assess the students' perspectives on the new strategy, and to compare the skills of students following the new curriculum to those of students following the traditional curriculum, who do not follow structured programmes on practical skills but experience a practical neonatology rotation. RESULTS: The evaluation of the CD-ROM program was very favourable. The majority of students still preferred live demonstrations but found the CD-ROM useful for revision purposes. With the exception of one skill, endotracheal intubation, the new curriculum students were found to be as competent as the students following the traditional curriculum and performed mask ventilation and cardiac massage significantly better than them.     

Skills and attributes of directors of educational programmes

OBJECTIVES: The purpose of this study was to obtain a list of desirable skills and attributes of prospective educational programme directors as judged by potential employers of future directors. DESIGN: An international mail survey was conducted worldwide, using a one-page, open-ended questionnaire. SETTING: University of Illinois at Chicago, USA. SUBJECTS: Deans, department heads and chief executive officers from the various health professions. RESULTS: A total of 139 respondents completed the questionnaire (22. 3% response rate). Responses were remarkably similar across health professions. The nine leading skills were: oral communication skills, interpersonal skills, competent practitioner, educational goal-definition skills, educational design skills, problem-solving and decision-making skills, team worker and building skills, written communication skills and fiscal manager and budgeting skills. The three leading personal attributes were: visionary, flexible and open-minded and trustworthy and value-driven individual. CONCLUSIONS: The complete list of skills and attributes can be used by employers or administrators to build checklist items when hiring or reviewing programme directors or to plan and evaluate training programmes. The importance of leadership compared to managerial responsibilities is discussed as well as the need to train future educational programme directors.     

Effects of conventional and problem-based learning on clinical and general competencies and career development

Objective  To test hypotheses regarding the longitudinal effects of problem-based learning (PBL) and conventional learning relating to students' appreciation of the curriculum, self-assessment of general competencies, summative assessment of clinical competence and indicators of career development.
Methods  The study group included 2 complete cohorts of graduates who were admitted to the medical curriculum in 1992 (conventional curriculum, n  =   175) and 1993 (PBL curriculum, n  =   169) at the Faculty of Medicine, University of Groningen, the Netherlands. Data were obtained from student records, graduates' self-ratings and a literature search. Gender and secondary school grade point average (GPA) scores were included as moderator variables. Data were analysed by a stepwise multiple and logistic regression analysis.
Results  Graduates of the PBL curriculum scored higher on self-rated competencies. Contrary to expectations, graduates of the PBL curriculum did not show more appreciation of their curriculum than graduates of the conventional curriculum and no differences were found on clinical competence. Graduates of the conventional curriculum needed less time to find a postgraduate training place. No differences were found for scientific activities such as reading scientific articles and publishing in peer- reviewed journals. Women performed better on clinical competence than did men. Grade point average did not affect any of the variables.
Conclusions  The results suggest that PBL affects self-rated competencies. These outcomes confirm earlier findings. However, clinical competence measures did not support this finding.     

The clinical and educational experiences of pre-registration house officers in general practice

AIMS: To describe aspects of the clinical experience and educational supervision gained by pre-registration house officers (PRHOs) in general practice, and to relate these to the current General Medical Council (GMC) aims for general clinical training in general practice. DESIGN: Qualitative evaluation, part of which involved semistructured interviews with 12 PRHOs who were experiencing a general practice rotation. Interviews were conducted at the beginning and the end of the pre-registration year, and following return to hospital work after completion of the general practice placement. SETTINGS: Three teaching hospitals, two district general hospitals and six general practices in south-east England. PARTICIPANTS: 12 PRHOs who were involved in rotations incorporating a general practice placement. RESULTS: To varying degrees, the GMC aims for training in general practice were met for all the participants. All PRHOs recognized the value of the clinical experience and educational supervision they received in general practice. They particularly valued aspects such as having an individual training programme based on their own needs, and the interlinking of theory and practice, which aided learning. Most felt that having responsibility for their own patients acted as an important incentive for learning, and in general, PRHOs appreciated having the time to learn which general practice allowed. CONCLUSIONS: For the majority of PRHOs, the time spent in general practice was seen as a positive clinical and educational experience. In a variety of ways, the general practice placement encouraged PRHOs to develop the self-directed learning skills seen as essential to the lifelong learning advocated by the GMC. A number of recommendations are made to help improve the integration of the hospital and general practice components of these rotations.     

Simulation in surgical training: educational issues and practical implications

BACKGROUND: Surgical skills are required by a wide range of health care professionals. Tasks range from simple wound closure to highly complex diagnostic and therapeutic procedures. Technical expertise, although essential, is only one component of a complex picture. By emphasising the importance of knowledge and attitudes, this article aims to locate the acquisition of surgical skills within a wider educational framework. SIMULATORS: Simulators can provide safe, realistic learning environments for repeated practice, underpinned by feedback and objective metrics of performance. Using a simple classification of simulators into model-based, computer-based or hybrid, this paper summarises the current state of the art and describes recent technological developments. Advances in computing have led to the establishment of precision placement and simple manipulation simulators within health care education, while complex manipulation and integrated procedure simulators are still in the development phase. EVALUATION: Tension often exists between the design and evaluation of surgical simulations. A lack of high quality published data is compounded by the difficulties of conducting longitudinal studies in such a fast-moving field. The implications of this tension are discussed. THE WIDER CONTEXT: The emphasis is now shifting from the technology of simulation towards partnership with education and clinical practice. This highlights the need for an integrated learning framework, where knowledge can be acquired alongside technical skills and not in isolation from them. Recent work on situated learning underlines the potential for simulation to feed into and enrich everyday clinical practice.     

Graduate status and age at entry to medical school as predictors of doctors' choice of long-term career

OBJECTIVE: To determine whether graduate entry to medical school, taking an intercalated degree during medical school, and age at entry to medical school are related to choice of eventual career. DESIGN: Postal questionnaires. SETTING: United Kingdom (UK). SUBJECTS: All doctors who qualified in the UK in 1993 or 1996. RESULTS: We analysed whether graduate status and age on entry to medical school, and taking an intercalated degree during medical school, were predictors of the choice of eventual career, adjusting for differences by sex, year of qualification and medical school. General practice was the career choice of 27.0% (79/293) of graduate entrants and 21.6% (1095/5073) of non-graduate entrants, a difference of borderline significance (P=0.04). Of the non-graduate entrants, general practice was the career choice of 15.3% (319/2081) of doctors who took an intercalated degree and 25.9% (776/2992) of doctors who did not (P < 0.001). Within the hospital specialties, those who took an intercalated degree were more likely than others to choose the hospital medical specialties or pathology. Age alone was not a predictor for choice of any area of practice. CONCLUSIONS: There was no evidence of an association between age at entry to medical school and choice of eventual career. Graduates at entry to medical school were a little more likely than non-graduates to choose general practice but the relationship was not a strong one. In these respects, changing the entry profile of medical students is unlikely to result in major shifts of career choice towards general practice.     

Medical career choice and practice location: early factors predicting course completion, career choice and practice location

AIMS: The overall aim of the study was to identify the factors that best predict medical career choice and practice location. METHOD: A longitudinal, cohort study was conducted. This followed 2 cohorts of students, numbering a total of 229 students, who commenced medical studies at the University of Western Australia in 1984 and 1989. Data concerning the students' sociodemographic backgrounds, admission scores and personality characteristics were collected in Year 1. Regression analyses were performed to identify the student characteristics that best predicted course completion, a choice of general practice 4 years after graduation and a rural location of practice. OUTCOMES: We found that students who had lower university admission scores and who were less outgoing were less likely to complete the course. Students who were male, had a father in medicine and were more creative and abstract in their thinking and more conscientious and rule-bound were more likely to choose a specialist career. A rural background was found to be the most important predictor of both rural general and specialist practice.     

Views of doctors in training on the importance and availability of career advice in UK medicine

OBJECTIVES: To determine whether doctors in their first year after qualification wanted career advice, and, if so, whether they thought they had been able to obtain useful advice, and whether older doctors thought that adequate career advice had been available to them. METHODS: We carried out a postal questionnaire survey of all UK medical graduates of 1988, 1993, 1996, 1999 and 2002, and a 25% random sample of the graduates of 2000. RESULTS: The response rate was 67.4% (24 261/35 976 mailed questionnaires). Of doctors in the first postgraduate year, 95% agreed that: 'It is important to be given career advice at this stage of training.' A total of 38% disagreed with the statement: 'I have been able to obtain useful career advice since graduation.' Of more experienced doctors surveyed between 3 and 11 years after graduation, 34% agreed that: 'Making career choices has been made more difficult by inadequate career advice.' CONCLUSIONS: The great majority of junior doctors want career advice after qualification. It cannot be assumed that they are able to seek it out for themselves satisfactorily. Career advice needs to be planned into postgraduate work and training.     

The impact of multifaceted educational structuring on learning effectiveness in a surgical clerkship

INTRODUCTION: Various measures have been introduced to enhance learning experiences in clerkships, generally with limited success. This study evaluated the impact of a multifaceted approach on the effectiveness of learning in a surgical clerkship. In accordance with results obtained in continuing medical education, several interventions were introduced simultaneously. We compared students' evaluations of the traditional surgical clerkship with those of the restructured clerkship. METHODS: Two consecutive cohorts of students were asked to complete a questionnaire about the quality and quantity of their learning experiences. Cohort 1 (n = 28) undertook the traditional clerkship and cohort 2 (n = 72) the restructured clerkship. A Mann-Whitney test was used to compare outcomes between the 2 cohorts. RESULTS: There were few statistically significant differences between cohorts 1 and 2. Overall, quality indicators did not differ between the 2 cohorts. DISCUSSION: A short-term multifaceted intervention led to a slight increase in the performance of clinical skills and a slight decrease in time spent on activities of limited educational value. The intervention may have been too brief to produce substantial effects. Future interventions should also target teachers, including trainees, in order to assess their opinions and address their educational needs.     

Variation by medical school in career choices of UK graduates of 1999 and 2000

OBJECTIVE: To report on how newly qualified doctors' specialty choices, and factors that influenced them, varied by medical school. DESIGN: Postal questionnaires. SETTING: United Kingdom. SUBJECTS: All doctors who graduated in the UK in 1999 and 2000. MAIN OUTCOME MEASURES: Choices of eventual career expressed 1 year after graduating, and factors influencing their choices. RESULTS: There were some significant differences between medical schools in the career choices made by their graduates. For example, the percentage of respondents who expressed the choice of general practice was significantly low among graduates of Oxford and Cambridge and high among graduates of Birmingham and Leicester. There was also significant variation between medical schools in choices for hospital medical and surgical specialties. There were significant differences, too, between medical schools in the extent to which career choices had been strongly influenced by graduates' inclinations before starting medical school and by their experience of their chosen specialty, particular teachers and departments at medical school. As well as the differences, however, there were also many similarities between the schools in graduates' career choices. DISCUSSION: Medical schools currently provide students with a broad training suited to any subsequent choice of specialty. We suggest that the similarities between schools in the career choices made by graduates are generally more striking than the differences. We raise the question of whether there should be any specialisation by individual schools to train students for careers in particular branches of medical practice.     

Acceptability and educational impact of a peer feedback model for significant event analysis

Context A model of independent, external review of significant event analysis by trained peers was introduced by NHS Scotland in 1998 to support the learning needs of general practitioners (GPs). Engagement with this feedback model has increased over time, but participants’ views and experiences are largely unknown and there is limited evidence of its educational impact. This is important if external feedback is to play a potential role in appraisal and future revalidation. Objective The study aimed to explore aspects of the acceptability and educational impact of this external feedback model with participating GPs. Methods Semi‐structured interviews were carried out with nine GPs. Participants were sampled to reflect their level of learning need (low, moderate or high) to gain a range of views and experiences. Transcribed interviews were analysed for content. Results This system of external peer feedback is generally acceptable to participants. It complemented and enhanced the appraisal process. External feedback had positive educational outcomes, particularly in imparting technical knowledge on how to analyse significant events. Training issues for peer reviewers were suggested that would further enhance the educational gain from participation. There was disagreement over whether this type of feedback could or should be used as supporting evidence of the quality of doctors’ work to educational and regulatory authorities. Conclusions The findings add to the evidence for the acceptability and educational impact of external review by trained peers. Aligning such a model with the current national appraisal system may provide GPs with a more robust demonstration of participation in reflective learning.     

Performance of State Medical Boards: Implications For Hospitals and Health Systems

The accountabilities and operations of state medical boards can have significant implications for hospitals and health systems in terms of their efforts to ensure quality care and patient safety. This study examined the performance of state medical boards and the reasons for variability in board performance by identifying factors impacting the performance of state medical boards in terms of physician discipline and those variables most critical to medical board performance. The findings suggested that increasing staff support and appointing lay board members would lessen the degree of variability in the performance of state boards although there remained a significant amount of variance to be explained.     

The impact of case specificity and generalisable skills on clinical performance: a correlated traits-correlated methods approach

Context  The finding of case or content specificity in medical problem solving moved the focus of research away from generalisable skills towards the importance of content knowledge. However, controversy about the content dependency of clinical performance and the generalisability of skills remains.
Objectives  This study aimed to explore the relative impact of both perspectives (case specificity and generalisable skills) on different components (history taking, physical examination, communication) of clinical performance within and across cases.
Methods  Data from a clinical performance examination (CPX) taken by 350 Year 3 students were used in a correlated traits−correlated methods (CTCM) approach using confirmatory factor analysis, whereby 'traits' refers to generalisable skills and 'methods' to individual cases. The baseline CTCM model was analysed and compared with four nested models using structural equation modelling techniques. The CPX consisted of three skills components and five cases.
Results  Comparison of the four different models with the least-restricted baseline CTCM model revealed that a model with uncorrelated generalisable skills factors and correlated case-specific knowledge factors represented the data best. The generalisable processes found in history taking, physical examination and communication were responsible for half the explained variance, in comparison with the variance related to case specificity.
Conclusions  Pure knowledge-based and pure skill-based perspectives on clinical performance both seem too one-dimensional and new evidence supports the idea that a substantial amount of variance contributes to both aspects of performance. It could be concluded that generalisable skills and specialised knowledge go hand in hand: both are essential aspects of clinical performance.     

Competency domains in an undergraduate Objective Structured Clinical Examination: their impact on compensatory standard setting

Context  Following a 15-week attachment in paediatrics and child health, general practice and dermatology medical students in their second clinical year at this medical school undertake a high-stakes assessment including an objective structured clinical examination (OSCE). There were 2 hypotheses. Firstly, groups of similar stations map to competency domains identifiable by factor analysis. Secondly, poor performance in individual domains is compensated for by achieving the required standard of performance across the whole assessment.
Methods  A total of 647 medical students were assessed by an OSCE during 5 individual examination sittings (diets) over 2 years. Ten scoring stations in the OSCE were analysed and confirmatory factor analysis performed comparing a 1-factor model (where all the stations are discrete entities related to one underlying domain) with a 3-factor model (where the stations load onto 3 domains from a previously reported exploratory factor analysis).
Results  The 3-factor model yielded a significantly better fit to the data (χ² = 15.3, P  <   0.01). Assessing the compensation data of 1 diet, 29 of 127 students failed in 1 or more domains described, whereas only 5 failed if compensation was allowed across all domains.
Discussion  Confirmatory factor analysis showed a significant fit of the data to previously described competency domains for a high-stakes undergraduate OSCE. Compensation within but not between competency domains would provide a more robust standard, improve validity, and substantially reduce the pass rate.     

上海市社会办医信用监管结果在行政许可中应用问题及对策分析

本文以应用为导向,通过信用监管在社会办医疗机构行政许可中应用的现状调查分析,依托现有数据平台,从守信激励及失信受限两方面出发,制定信用监管在社会办医疗机构行政许可应用问题及对策分析,完善事前、事中、事后监管执法领域信用监管机制.