Cognitive metaphors of expertise and knowledge: prospects and limitations for medical education

CONTEXT: Many approaches to the study of expertise in medical education have their roots most strongly established in the traditional cognitive psychology literature. As such, they take a common approach to the construction of expertise and frame their questions in a common way. This paper reflects on a few of the paradigmatic assumptions that have 'come along for the ride' with the traditional cognitive approach, and explores what might have been left out as a consequence. METHODS: We examine the operational definition of 'expert' as it has evolved using the traditional cognitive paradigm and we explore some alternative definitions and constructions of expert performance that have arisen in parallel education research paradigms. We address 3 inter-related aspects of expertise as manifested in the traditional cognitive approach: the construction of the expert as a (routine) diagnostician; the construction of the developmental process as the (automatic and un-reflective) accrual of resources through experience, and the construction of accrued knowledge as a relatively static resource that is subsequently used and built upon with further experience. CONCLUSIONS: We hope that, by highlighting these issues, we may begin to marry the strengths of the traditional cognitive paradigm with the strengths of these other paradigms and expand the scope of cognitive research in medical expertise.     

Medical problem-solving: an exploration of strategies

In contrast to factual knowledge the reasoning processes of doctors in their attempts to clarify the patient's problem has been a somewhat neglected domain of study. The rise of experimental psychology, clinical decision analysis, and problem-based learning fostered studies in this area. Several studies from different viewpoints have been performed, leading to a more profound understanding of these processes. I approached the issue from a general physician viewpoint which reverted to the old distinction between deductive and inductive reasoning. Within a group of 68 participating doctors (family doctors and general physicians) the inductive method was exclusively employed. From this finding we conjecture that the inductive type of reasoning is the predominant style in the medical world. The consequences as attached to the overall utilization of the inductive method are far-reaching. Among others, process retracing as a feedback mechanism fails to function when it results from the intuitive nature of the (pattern-recognition) process. As a consequence we do not and can not know what we may learn from experience, good things as well as bad things. The inductive method is a method of practice and quick reaction, but it leaves us empty-handed as far as understanding and teaching are concerned.     

Facility with the English language and problem-based learning group interaction: findings from an Arabic setting

The Faculty of Medicine and Health Sciences (FMHS), United Arab Emirates (UAE) University is in a unique position to explore issues related to English language proficiency and medical student performance. All students entering the FMHS have English as a second language. This study focused on the issues of students' proficiency in English as measured by the TOEFL test, student background factors and interaction in problem-based learning (PBL) groups. Using a modification of Bales Interaction Process Analysis, four problem-based learning groups were observed over four thematic units, to measure the degree of student interaction within PBL groups and to compare this to individual TOEFL scores and key background variables. The students' contributions correlated highly with TOEFL test results in the giving of information (range r = 0.67-0.74). The female students adhered to interacting in English during group sessions, whereas the male students were more likely to revert to using Arabic in elaborating unclear phenomena (p < 0.01). The educational level of the student's mother was highly predictive of TOEFL scores for the male students, but not for female students. Multivariate analysis was undertaken to analyse the relative contribution of the TOEFL, parental education and years of studying in English. The best predictor of students' contributions in PBL groups was identified as TOEFL scores. The study demonstrates the importance of facilitating a locally acceptable level of English proficiency prior to admission to the FMHS. However, it also highlights the importance of not focusing only on English proficiency but paying attention to additional factors in facilitating medical students in maximizing benefits from interactions in PBL settings.     

Racial and sexual discrimination in the selection of students for London medical schools

Analysis of the names of students from London medical schools taking their final examinations in June 1982, 1983 and 1984 has revealed that racial and sexual discrimination operate when students are selected for medical education. On the basis of name the ratios of European to African, Asian or Arabic students vary significantly between the two extreme schools (P less than 0.01), and for any school the proportion tends to be consistent from year to year. Differences also occur between the proportion of females at each school. Furthermore, the pattern of racial and sexual discrimination at each school shows a highly significant rank correlation (r = 0.77). The admission policies at the different London medical schools need to be reviewed.     

Disease prevention and health promotion: a study of medical students and teachers

All students at the Royal Free Hospital School of Medicine (n = 508 ) were surveyed on their self-reported smoking and drinking habits, attitudes to disease prevention and health promotion in general, attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught at the beginning of the 1993–1994 academic year (response rate 75.2%). The teaching staff (n = 271 ) were also surveyed on their attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught (response rate 74.2%). Seventeen per cent of the students reported they were current smokers and 81% drank alcohol. Four factors were extracted from the responses to the items on disease prevention and health promotion in general and these represented the importance of health, a patient-centred approach, patient responsibility and a doctor-centred approach. Clinical students and those who were older were more likely to have a ‘patient-centred’ approach to disease prevention and health promotion. Sixty per cent of clinical and 44% of pre-clinical teachers aimed to teach about disease prevention and health promotion. The topics reported by students as most likely to have been taught in detail are smoking and health, alcohol and health, immunization, and breast and cervical screening. However, all these topics were reported as having been taught in detail by less than 50% of the students. The majority of students and teachers believe that teaching about disease prevention and health promotion should be integrated into all years of the curriculum and all clinical firms. Teachers were significantly less likely than students to believe that students should learn more about disease prevention and health promotion, and that learning about prevention is as important as learning about diagnosis and treatment. We believe that, in order to build on the positive features highlighted in this study, agreed aims and objectives should be developed and teaching about disease prevention and health promotion should be integrated both horizontally and vertically throughout the curriculum.     

The effect of defined violations of test security on admissions outcomes using multiple mini-interviews

INTRODUCTION: Heterogeneous results exist regarding the impact of security violations on student performances in objective structured clinical examinations (OSCEs). Three separate studies investigate whether anticipated security violations result in undesirable enhancement of MMI performance ratings. METHODS: Study 1: low-stakes: MMI station stems provided to a random half of 57 medical school applicants 2 weeks in advance of participation in a research study. Study 2: high-stakes: 384 medical school applicants sat a 12-station MMI to determine admission. Each half received 1 of 2 pilot MMI station stems 2 weeks in advance. Study 3: high-stakes: 38 interviewees with dual applications to occupational therapy and physiotherapy experienced the same 7-station MMI twice on the same date. RESULTS: No statistically significant differences in MMI performances were detected. CONCLUSIONS: Predictable violations of MMI security do not unduly influence applicant performance ratings.     

Aspects of differential role perception of Israeli medical school students

Attitudes of first year Israeli Medical School students are investigated using the Semantic Differential technique to differentiate their perceptions of the roles of doctor, patient and the mentally ill. Students also selected from among thirty-four behavioural traits those roles considered most characteristic of doctor and/or patient. A high degree of certainty and of role stereotyping is found of doctor image. This may be associated with past experiences as child-patient, with idealizations and identifications and with future aspirations. There is less consensus with the role of patient but there are clear attitudinal boundaries among students between roles. The doctor is perceived as an idealized, if authoritarian, person meeting with a rather negatively but more flexibly perceived person of the patient. Behavioural traits selected by the students are consonant with this finding. The results are discussed in the context of identification patterns and the educational process.     

The selection and training of examiners for clinical examinations

The inconsistency of the marking in clinical examinations is a well documented problem. This project identified some of the factors responsible for this inconsistency.
A standardized rating situation was devised. Five students were videotaped as they performed part of a physical examination on simulated patients. Eighteen experienced medical and surgical examiners rated their performances using an objective checklist type of rating form. No differences were evident between physicians and surgeons. The group of examiners was divided into three subgroups, one receiving no training, one limited training and one more extensive training. Examiners re-rated the same students 2 months after the first rating.
Inter-rater reliability was satisfactory for the first ratings and training produced no significant improvement. A substantial improvement was achieved by identifying the most inconsistent raters and removing them from the analysis. Training was shown to be unnecessary for consistent examiners and ineffective for examiners who were less consistent. On the basis of these results, only consistent examiners were selected to take part in the interactive component of the objective structured final year examinations. The ratings in these examinations achieved high levels of inter-rater reliability.
It was concluded that the combination of an objective check-list rating form, a controlled test situation and the selection of inherently consistent examiners could solve the problem of inconsistent marking in clinical examinations.     

An approach to mathematical literacy for medical students

Mathematical literacy is defined as the ability to read and interpret information of a mathematical nature. Based on the empirically determined needs of medical students in this area, a set of instructional materials (tests, text, and technical manual) were produced and successfully used. These results are described here as are considerations bearing on the generalizability of the described approach.     

Students evaluate medfile, a preprinted medical literature filing system

Medical professionals are highly dependent on personal libraries and reprint files as their sources for current information. A large population of practising doctors have poorly organized medical literature data bases in their professional environment. To expedite the development of a personal library data base by medical students, we created MEDFILE, a preprinted, cross-indexed file folder system for organizing the medical literature. This paper reports the results of two surveys performed in connection with the distribution of the MEDFILE system. One hundred per cent of the students who used MEDFILE found the system to be beneficial. Ninety-seven per cent felt their ability to find their personal literature improved by using MEDFILE, and 65% felt MEDFILE improved their clinical preparation. Of all surveyed recipients of the system, 96.8% felt MEDFILE would be useful in their future studies.     

Establishing community-orientated medical schools: key issues and steps in early planning

OBJECTIVES: To describe briefly the process of early planning and establishment of community-based medical schools with highlights of the key issues and milestones. DESIGN: After outlining some basic concerns and provisos for the Dean and suggested strategies for setting the stage (preparing the ground) for the innovation, three phases of early planning and action steps within each are listed to serve as a guide and a general checklist. SETTING: University of Gezira, Sudan and UAE University, AL-Ain. CONCLUSION: As the curriculum with its implications constitutes the driving force for establishing the schools, it has been given due emphasis and greater share in planning. The communication is concluded with further advice to founding Deans through the proposition of a five-star Dean.     

Knowledge and clinical problem-solving

A consistent finding in the literature on measures of clinical problem-solving scores is that there are very low correlations across different problems. This phenomenon is commonly labelled 'content-specificity', implying that the scores differ because the content knowledge necessary to solve the problems differs. The present study tests this hypothesis by presenting groups of residents and clinical clerks with a series of simulated patient problems in which content was systematically varied. Each subject also completed a multiple choice test with questions linked to each diagnosis presented in the clinical problems. Three of the four problem-solving scores showed low correlations, even to two presentations of the same problem, and no relationship to content differences. None of the scores were related to performance on the multiple choice test. The results suggest that variability in problem-solving scores is related to factors other than content knowledge, and several possibilities are discussed.     

House officers'' attitudes towards terminal care

This study examined the change in doctor's knowledge, attitudes and management of the terminally ill during the pre-registration year. There was a slight improvement in the factual knowledge of most house officers, but some showed a deterioration in their understanding of the problems of the terminally ill. There were marked deficits in knowledge of symptom control. The house officers' own experience of serious illness or bereavement did not alter their measured knowledge or attitudes to the patients.     

The validity of clerkship performance evaluations

The validity of narrative evaluations of clinical performance in medical school was investigated for three successive classes of medical school graduates. The criteria were ratings obtained from residency supervisors one year after entering the programme. Bivariate correlational analysis, multiple regression analysis and canonical redundancy analysis were performed to examine the associations between the evaluations by teachers of competence in medical school clerkships and the subsequent ratings by residency supervisors. The results, best summarized in the canonical analysis, showed two relationships between the two sets of measures (lambda 1 = 0.54 and lambda 2 = 0.47). The first relationship revealed an overall-competence-in-medicine dimension; the second suggested an interpersonal-skills/professional-maturity dimension. Overall, knowledge of clerkship performance accounted for 15% of the variance in residency ratings. The findings suggest the need to improve the assessment of professional maturity and behaviour during medical school.     

Language background, proficiency in English, and selection for language development

With a diverse language background profile in an Australian medical student population, teaching interventions are necessary for students whose English language proficiency is not adequate for the study of medicine. This paper describes the screening of written and aural English language proficiency in 143 first year undergraduate students using a standardized instrument. Students identified as experiencing language difficulties were subsequently assessed by interview and allocated to faculty-based Language Development Programme. Students with the greatest need for language support participated in a full 2 year programme. Those requiring less assistance were offered more limited support in the form of specific modules within the programme. Students allocated to the full programme were significantly weaker in language proficiency compared to those offered specific modules and those not offered a placement. The information gathered during the structured interview is valuable in establishing for medical educators specific areas in which language-related teaching for students who require it can be directed. Future research is required to evaluate the effectiveness of faculty-based language interventions in terms of improvement in language proficiency over time and the effect of any improvements in language proficiency on academic and clinical performance.     

Course in massage therapy for medical students

Massage courses for medical students have been held at Frankfurt University Medical School since 1987. To evaluate the motives for participation and to record possible changes in the attitude towards massage therapy, the students were asked to fill out a standardized questionnaire in 1990, 1993 and 1995/96. The results show that the motive for participation and the attitude towards massage therapy remained widely unchanged during these years. Summarizing all data (n = 199) the motives for participation were: (1) to practise massage therapy (86%), (2) to be better able to (later) prescribe massage therapy (66%), (3) to improve palpation skills (75%), (4) to do 'something practical' (56%), and (5) to (later) practise massage therapy as a medical doctor (23%). On average, the proportion of theory and practical instruction of 1:3.2 was considered suitable.     

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.     

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.