Do students have sufficient knowledge of clinical anatomy?

INTRODUCTION: Comparisons of anatomy knowledge levels of students from various curricula show either no differences or small differences to the detriment of innovative schools. To pass judgement on the general level of students' anatomy knowledge, we need an absolute standard. The purpose of this study was to compare students' levels of anatomy knowledge as measured by a case-based anatomy test with standards set by different groups of experts. METHODS: A modified Angoff procedure was used to establish an absolute standard against which the students' results could be evaluated. Four panels of 9 anatomists, 7 clinicians, 9 recent graduates and 9 Year 4 students, respectively, judged 107 items of an anatomy test. The students' results on these items were compared with the standards obtained by the panels. RESULTS: If the standard established by the panel of Year 4 students was used, 64% of the students would fail the test. The standards established by the anatomists, clinicians and recent graduates would yield failure rates of 42%, 58% and 26%, respectively. CONCLUSION: According to the panels' standards, many students did not know enough about anatomy. The high expectations that the Year 4 students appeared to have of their peers may contribute to students' uncertainty about their level of anatomy knowledge.     

What clinical information resources are available in family physicians' offices?

BACKGROUND: When faced with questions about patient care, family physicians usually turn to books in their personal libraries for the answers. The resources in these libraries have not been adequately characterized. METHODS: We recorded the titles of all medical books in the personal libraries of 103 randomly selected family physicians in eastern Iowa. We also noted all clinical information that was posted on walls, bulletin boards, refrigerators, and so forth. Participants were asked to describe their use of other resources such as computers, MEDLINE, reprint files, and "peripheral brains" (personal notebooks of clinical information). For each physician, we recorded how often the resources were used to answer clinical questions during 2 half-day observation periods. RESULTS: The 103 participants owned a total of 5794 medical books, with 2836 different titles. Each physician kept an average of 56 books in the office. Prescribing references (especially the Physicians' Desk Reference) were most common (owned by 100% of the participants), followed by books on general internal medicine (99%), adult infectious disease (89%), and general pediatrics (83%). Books used to answer clinical questions were more likely to be up to date (copyright date within 5 years) than unused books (74% vs 27%, P <.001). Items posted on walls included drug dosage charts and pediatric immunization schedules. Only 26% of the physicians had computers in their offices. CONCLUSIONS: Drug-prescribing textbooks were the most common type of book in family physicians' offices, followed by books on general internal medicine and adult infectious diseases. Although many books were relatively old, those used to answer clinical questions were generally current.     

Do taught courses on community medicine change knowledge status regarding clinical epidemiology and biostatistics in medical students?

This study aimed to explore the changes in medical student's knowledge and attitudes regarding clinical epidemiology and biostatistics (CEB) after community medicine (CM) taught courses. All the 3rd (before CM-taught courses) and 4th year (after CM-taught courses) undergraduate students of Dhaka Medical College, Bangladesh, were given a questionnaire concerning some introductory level problems on CEB and attitudes towards them. Mean knowledge scores were not statistically different between these two groups: 3.70 and 3.85 (out of 9) on clinical epidemiology; 0.20 and 0.18 (out of 4) on biostatistics; and 3.91 and 4.04 as a total (out of 13) among them, respectively. Most of the 3rd and 4th year students agreed that CEB is essential for smooth understanding of clinical medicine and journals, and asserted to include it in CM-taught courses. Since the current CM-curriculum does not offer any improvement of knowledge among them, well-planned taught courses on it should be included as a component of CM.     

Do clinical practice education groups result in sustained change in GP prescribing?

BACKGROUND: Concern has been expressed at the poor uptake of evidence into clinical practice. This is despite the fact that continuing education is an embedded feature of quality assurance in general practice. There are a variety of clinical practice education methods available for dissemination of new evidence. Recent systematic reviews indicate that the effectiveness of these different strategies is extremely variable. OBJECTIVE: Our aim was to determine whether a peer-led small group education pilot programme used to promote rational GP prescribing is an effective tool in changing practice when added to prescribing audit and feedback, academic detailing and educational bulletins, and to determine whether any effect seen decays over time. METHODS: A retrospective analysis of a controlled trial of a small group education strategy with 24 month follow-up was carried out. The setting was an independent GPs association (IPA) of 230 GPs in the Christchurch New Zealand urban area. All intervention and control group GPs were already receiving prescribing audit and feedback, academic detailing and educational bulletins. The intervention group were the first 52 GPs to respond to an invitation to pilot the project. Two control groups were used, one group who joined the pilot later and a second group which included all other GPs in the IPA. The main outcome measures were targeted prescribing data for 12 months before and 24 months after each of four education sessions. RESULTS: An effect in the expected direction was seen in six of the eight key messages studied. This effect was statistically significant for five of the eight messages studied. The effect size varied between 7 and 40%. Where a positive effect was seen, the effect decayed with time but persisted to a significant level for 6-24 months of observation. CONCLUSION: The results support a positive effect of the education strategy on prescribing behaviour in the intervention group for most outcomes measured. The effect seen is statistically significant, sustained and is in addition to any effect of the other pharmaceutical educational initiatives already undertaken by the IPA.     

Do Medicare Advantage plans select enrollees in higher margin clinical categories?

The CMS-HCC risk adjustment system for Medicare Advantage (MA) plans calculates weights, which are effectively relative prices, for beneficiaries with different observable characteristics. To do so it uses the relative amounts spent per beneficiary with those characteristics in Traditional Medicare (TM). For multiple reasons one might expect relative amounts in MA to differ from TM, thereby making some beneficiaries more profitable to treat than others. Much of the difference comes from differences in how TM and MA treat different diseases or diagnoses. Using data on actual medical spending from two MA-HMO plans, we show that the weights calculated from MA costs do indeed differ from those calculated using TM spending. One of the two plans (Plan 1) is more typical of MA-HMO plans in that it contracts with independent community providers, while the other (Plan 2) is vertically integrated with care delivery. We calculate margins, or average revenue/average cost, for Medicare beneficiaries in the two plans who have one of 48 different combinations of medical conditions. The two plans’ margins for these 48 conditions are correlated (r = 0.39, p < 0.01). Both plans have margins that are more positive for persons with conditions that are managed by primary care physicians and where medical management can be effective. Conversely they have lower margins for persons with conditions that tend to be treated by specialists with greater market power than primary care physicians and for acute conditions where little medical management is possible. The two plan's margins among beneficiaries with different observable characteristics vary over a range of 160 and 98 percentage points, respectively, and thus would appear to offer substantial incentive for selection by HCC. Nonetheless, we find no evidence of overrepresentation of beneficiaries in high margin HCC's in either plan. Nor, using the margins from Plan 1, the more typical plan, do we find evidence of overrepresentation of high margin HCC's in Medicare more generally. These results do not permit a conclusion on overall social efficiency, but we note that selection according to margin could be socially efficient. In addition, our findings suggest there are omitted interaction terms in the risk adjustment model that Medicare currently uses.     

Cognitive apprenticeship in clinical practice: can it stimulate learning in the opinion of students?

Learning in clinical practice can be characterised as situated learning because students learn by performing tasks and solving problems in an environment that reflects the multiple ways in which their knowledge will be put to use in their future professional practice. Collins et al. introduced cognitive apprenticeship as an instructional model for situated learning comprising six teaching methods to support learning: modelling, coaching, scaffolding, articulation, reflection and exploration. Another factor that is looked upon as conducive to learning in clinical practice is a positive learning climate. We explored students’ experiences regarding the learning climate and whether the cognitive apprenticeship model fits students’ experiences during clinical training. In focus group interviews, three groups of 6th-year medical students (N = 21) discussed vignettes representing the six teaching methods and the learning climate to explore the perceived occurrence of the teaching methods, related problems and possibilities for improvement. The students had experienced all six teaching methods during their clerkships. Modelling, coaching, and articulation were predominant, while scaffolding, reflection, and exploration were mainly experienced during longer clerkships and with one clinical teacher. The main problem was variability in usage of the methods, which was attributed to teachers’ lack of time and formal training. The students proposed several ways to improve the application of the teaching methods. The results suggest that the cognitive apprenticeship model is a useful model for teaching strategies in undergraduate clinical training and a valuable basis for evaluation, feedback, self-assessment and faculty development of clinical teachers.     

Do clinical practice guidelines reflect research evidence?

OBJECTIVES: To examine whether existing clinical practice guidelines (CPGs) for cholesterol testing reflect research evidence and hence may control or reduce costs while maintaining or improving the quality of care. METHODS: A systematic search for published and unpublished cholesterol testing CPGs and independent critical appraisal of the CPGs by two researchers using a standard checklist. RESULTS: In four of the five CPGs analysed, the link between the research evidence and the recommendations was not maintained. The appraisal, local experience and the literature all suggest that panel composition is an important explanation, in that the greater the involvement of clinical experts in the development process of the CPGs, the less the recommendations reflected the research evidence. Even though their participation is important for CPG uptake, clinical expert panels appear to have difficulty limiting CPGs to research-based recommendations. CONCLUSIONS: Existing cholesterol testing CPGs are unlikely to improve the quality of care while controlling or reducing costs. The problem lies not with guideline implementation but with the guidelines themselves. It is unclear how best to ensure that recommendations reflect research evidence but this is likely to require significant and progressive changes to the current guideline development process, including a redefinition of the clinical experts' role.     

Do financial incentives trump clinical guidance? Hip Replacement in England and Scotland

Following devolution in 1999 England and Scotland's National Health Services diverged, resulting in major differences in hospital payment. England introduced a case payment mechanism from 2003/4, while Scotland continued to pay through global budgets. We investigate the impact this change had on activity for Hip Replacement. We examine the financial reimbursement attached to uncemented Hip Replacement in England, which has been more generous than for its cemented counterpart, although clinical guidance from the National Institute for Clinical Excellence recommends the later. In Scotland this financial differential does not exist. We use a difference-in-difference estimator, using Scotland as a control, to test whether the change in reimbursement across the two countries had an influence on treatment. Our results indicate that financial incentives are directly linked to the faster uptake of the more expensive, uncemented Hip Replacement in England, which ran against the clinical guidance.     

Where do college students get health information? Believability and use of health information sources

This study aims to identify predictors of use of health information sources among U.S. college students. For this purpose, the Spring 2006 American College Health Association-National College Health Assessment (ACHA-NCHA) database of 94,806 students at 117 colleges and universities was used. Univariate and multivariable analyses of survey data were conducted. The four most believable sources of health information as indicated by survey respondents were health center medical staff, health educators, faculty or coursework, and parents. Health center medical staff, health educators, and faculty or coursework were underutilized in relation to their perceived believability, whereas parents were both used and believed at high frequencies. In general, older students, females, full time students, and Black and Hispanic students were more likely to use information from one of the four health sources. However, there was considerable subgroup variability, especially in the use of parents as a health information source. The authors conclude that information on use and believability of health information sources can help colleges to design more effective health information campaigns.     

Do adults who believe in periodic health examinations receive more clinical preventive services?

BACKGROUND: Individuals who have periodic health examinations ("check-ups") with physicians even if they feel well have higher rates of screening and other preventive services than individuals who only see physicians when ill. This study assessed whether individuals' beliefs about the advisability of periodic health examinations contribute to the likelihood that they receive recommended clinical preventive services. METHODS: This study used data from a 2002-2003 telephone survey of adults in 150 rural counties in 8 states of the U.S. southeast. Weighted Chi-square and logistic regression analyses were used to assess associations between attitudes towards periodic health examinations and the receipt of preventative services. RESULTS: Of the 4879 respondents, 37% were African American, and 43% had annual household incomes of less than $25,000. A total of 8.5% (n=374) did not endorse periodic health examinations. Not endorsing periodic examinations was more common among subjects who were male, younger, white and had no health insurance. Compared to those who endorsed periodic examinations, persons who did not were less likely to have had a periodic examination (42% versus 80%, p<0.001) or mammogram (28% versus 60%, p<0.001) in the previous year, a Pap smear in past 3 years (74% versus 90%, p<0.001), a cholesterol check in the last 5 years (56% versus 81%, p<0.001) or to ever have had endoscopic screening (28% versus 48%, p<0.001). These rate differences remained after adjusting for sociodemographic characteristics. CONCLUSION: People's beliefs about the value of periodic health examinations are associated with the likelihood that they receive recommended preventative services. Understanding individuals' beliefs about health, disease prevention and the role of physicians in prevention could lead to improved targeted interventions aimed at increasing uptake of preventative services.     

Do extended matching multiple-choice questions measure clinical reasoning?

PURPOSE: At the Faculty of Medicine at the Katholieke Universiteit Leuven, Belgium, we have developed a final examination that consists of extended matching multiple-choice questions. Extended matching questions (EMQs) originate from a case and have 1 correct answer within a list of at least 7 alternatives. If EMQs assess clinical reasoning, we can assume there will be a difference between the ways students and experienced doctors solve the problems within the questions. This study compared students' and residents' processes of solving EMQs. METHODS: Twenty final year students and 20 fourth or fifth year residents specialising in internal medicine solved 20 EMQs aloud. All questions concerned diagnosis or pathogenesis. Ten EMQs related to internal medicine and 10 questions to other medical disciplines. The session was audio-taped and transcribed. RESULTS: The residents correctly answered significantly more questions concerning internal medicine than did the students. Their reasoning was more "forward" and less "backward". No difference between residents and students was found for the other questions. The residents scored better on internal medicine than on the other questions. They used more backward and less forward reasoning when solving the other questions than they did with the internal medicine questions. The better half of the respondents used significantly more forward and less backward reasoning than did the poorer half. CONCLUSION: In accordance with the literature, medical expertise was characterised by forward reasoning, whereas outside their area of expertise, the subjects switched over to backward reasoning. It is possible to assess processes of clinical reasoning using EMQs.     

National clinical portal programme: what information do doctors want?

Electronic patient health information in secondary care is often stored on different IT systems and not accessible to doctors involved in clinical decision-making. The Scottish Government will support clinical portal implementation in all Scottish Health Boards, which will present information from different sources as a virtual electronic patient record. An online survey was developed and sent to secondary care doctors, who were asked to rank the importance of different types of patient-centred information, knowledge support sources, and information to support appraisal and continued professional development that a clinical portal could deliver. Subgroup analysis was performed to investigate whether expectations differed between senior clinicians and doctors in training. Replies were received from 677 senior doctors and 137 trainees. Patient-centric information such as current medication and allergies, clinical alerts, past medical history, diagnostic test results and clinical letters were ranked as most important. Doctors would also like access to knowledge support, such as clinical guidelines. Eighteen of the top 20 ranked information types were consistent between senior doctors and those in training grades. In conclusion, senior doctors and trainees consistently want to see similar information in the clinical portal which is largely patient-centred with some provision for knowledge support.     

Early clinical experience: do students learn what we expect?

Medical Education 2011: 45 : 731–740 Context Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged. Objectives This study describes students’ learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment. Methods A questionnaire containing open‐ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses. Results Students’ learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self‐reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes. Conclusions Students’ learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under‐represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students’ professional development are neglected in the first year of medical education.     

Medical students’ emotional development in early clinical experience: a model

Dealing with emotions is a critical feature of professional behaviour. There are no comprehensive theoretical models, however, explaining how medical students learn about emotions. We aimed to explore factors affecting their emotions and how they learn to deal with emotions in themselves and others. During a first-year nursing attachment in hospitals and nursing homes, students wrote daily about their most impressive experiences, explicitly reporting what they felt, thought, and did. In a subsequent interview, they discussed those experiences in greater detail. Following a grounded theory approach, we conducted a constant comparative analysis, collecting and then interpreting data, and allowing the interpretation to inform subsequent data collection. Impressive experiences set up tensions, which gave rise to strong emotions. We identified four ‘axes’ along which tensions were experienced: ‘idealism versus reality’, ‘critical distance versus adaptation’, ‘involvement versus detachment’ and ‘feeling versus displaying’. We found many factors, which influenced how respondents relieved those tensions. Their personal attributes and social relationships both inside and outside the medical community were important ones. Respondents’ positions along the different dimensions, as determined by the balance between attributes and tensions, shaped their learning outcomes. Medical students’ emotional development occurs through active participation in medical practice and having impressive experiences within relationships with patients and others on wards. Tensions along four dimensions give rise to strong emotions. Gaining insight into the many conditions that influence students’ learning about emotions might support educators and supervisors in fostering medical students’ emotional and professional development.     

Do consultations in rural general practice take more time when practitioners are precepting medical students?

CONTEXT: At Flinders University, Adelaide, a subset of students on the 4-year, graduate-entry medical course chooses to spend Year 3 based in rural general practice as part of the Parallel Rural Community Curriculum (PRCC). This programme is equivalent to the tertiary teaching hospital option in terms of student educational outcomes. However, there is concern that this success comes at the cost of lost consulting time for the general practitioners (GPs) who supervise these students. OBJECTIVE: This study aimed to quantify the impact of medical students on the consulting time of rural GP supervisors. METHODS: We carried out a prospective cohort study using analysis of videotape recordings. Study subjects were GPs supervising PRCC medical students and working from their own consulting rooms in the clinic setting. Main outcome measures were mean consultation times in sessions with and without medical students. RESULTS: Using mixed model analysis accounting for clustering of consultations within doctors, and controlling for confounding factors, the estimated marginal mean of regular consultation time was 13 minutes, 27 seconds, which was not significantly shorter than that of precepting consultations (12 minutes, 48 seconds) or parallel consultations (12 minutes, 24 seconds). CONCLUSIONS: Consultation length does not increase when rural GPs supervise medical students using a parallel consulting model.