Professional development in undergraduate medical curricula – the key to the door of a new culture?

CONTEXT: One of the most pressing requirements for contemporary medical education is to develop a framework for theory and practice of professional development which results in the attainment of professional competencies suitably robust for a lifetime's practice. The proposed content of a professional development curriculum may be reasonably straightforward to establish from policy documents and public expectations, but the process of achieving the desired outcomes is more complex, because professional development is largely based on attitudinal learning. Attitudes are at the interface between the personal and public psyche, relying more on individual experience and the accumulated impact of social and cultural interpretations than on propositional knowledge, and are therefore less amenable to factual or didactic teaching. AIMS: The purpose of this discussion paper is to develop thinking on the conceptual frameworks which need to underpin curriculum decision-making for professional development, especially in undergraduate medical training where models of good practice are less well-established. It brings together work from educational, sociological and psychological perspectives to elucidate the key principles which are most likely to result in acquisition of desirable professional attributes. IMPLICATIONS: The literature suggests that successful professional development needs to be based on explicit values, which are repeatedly demonstrated in the learning environment, and modelled by senior colleagues and tutors; that the curriculum should incorporate a clear model of emotional as well as cognitive development; should be a major component of summative assessment; and needs to include formative mentorship at all stages of training.     

Problem-solving skills, solving problems and problem-based learning

This paper reviews the empirical evidence in support of the three concepts in the title. To the extent that a skill should be a general strategy, applicable in a variety of situations, and independent of the specific knowledge of the situation, there is little evidence that problem-solving skills, as described and measured in medical education, possess these characteristics. Instead there is an accumulation of evidence that expert problem-solving in medicine is dependent on (I) a wealth of prior specific experiences which can be used in routine solution of problems by pattern recognition processes, and (2) elaborated conceptual knowledge applicable to the occasional problematic situation. The use of problem-based learning (PBL) as an educational strategy is explored. In particular, the evidence suggesting the compatibility of PBL with this theory of expertise is discussed. Finally, I review some issues in the design of PBL curricula from the perspective of the proposed model of expertise.     

Developing professional clinical skills for practice – the results of a feasibility study using a reflective approach to intimate examination

Objectives  To develop a student-selected component (SSC) for junior medical students, to evaluate the feasibility of incorporating the development of skills in carrying out an intimate examination, whilst developing professional thinking skills using a reflective approach.
Subjects  The student selected component was designed for a maximum of 6 students over a 4-week period in Phase 2 (year 2 and 3) of the undergraduate medical curriculum.
Setting  The Clinical Skills Centre, the Faculty of Medicine Nursing and Dentistry, University of Dundee, Scotland, UK.
Methods  The SSC consisted of a weekly patient clerking from the ward, an analysis of the clinical and communication skills for any intimate examinations the patient would require, and practice using simulators and simulated patients. Students were supported by timed periods of structured reflection, which enabled them to discuss ethical issues and their own professional conduct related to carrying out an intimate examination. The SSC was evaluated on 3 levels; student satisfaction, learning professional thinking using a reflective approach, and observing behaviour change in relation to skill development, using a ward simulation exercise.
Results  The evaluation at the levels of student satisfaction, learning professional thinking and changes in behaviour associated with intimate examination demonstrated that the SSC had been well received by the students, who felt they had improved their skills in intimate examinations in the context of a ward simulation exercise, in parallel with their professional thinking skills.
Conclusion  It is possible to develop the professional thinking of junior medical students at the same time as developing their technical competence in relation to intimate examinations. It may be advantageous to introduce students early to this reflective approach, using simulation to promote the integration of theory with practice.     

'Science', 'critical thinking' and 'competence' for tomorrow's doctors. A review of terms and concepts

CONTEXT: The recommendations of the General Medical Council in Tomorrow's Doctors renewed efforts to define core knowledge in undergraduate medical education. They also encouraged better use of the medical knowledge base in nurturing clinical judgement, critical thinking, and reflective practice. What then does the medical world understand by 'science', 'critical thinking' and 'competence', given the need to address both growth and uncertainty in the knowledge base and to practise evidence-based healthcare? AIM AND OBJECTIVES: This review aims to outline the role of these key concepts in preparing undergraduate medical students for professional practice. Specifically, it explores: the fallibility of the 'scientific' foundations of medical practice; the role of understanding and thinking in undergraduate medical education; the need for a broad interpretation of competence and its relationship to transferability, and the nature of clinical judgement. COMMENT: Tensions are seen to lie in the varying interpretations of clinical decision making as art or science; the varying characterizations of the nature of skilled performance in the novice, the competent and the expert practitioner, and the varying reactions to the acceptability and usefulness of 'meta-' concepts in capturing the essence of professional practice. Habitual self-conscious monitoring of mental processes may be the key to the flexible transfer and application of knowledge and skills across the contexts, characterized by uncertainty and incomplete evidence, for which doctors must be prepared.     

Introducing a problem-based unit into a lifespan nutrition class using a randomized design produces equivocal outcomes

Problem-based learning (PBL) is a tutorial, student-centered, problem-driven educational strategy adopted by medical and allied health educators to positively influence self-directed learning, critical thinking, and learning behavior. PBL was examined in dietetics education through random assignment of 32 undergraduate dietetics students for two weeks to either a problem-based or a lecture-based case format for the infant and elderly units of a 16-week lifespan nutrition course. Random assignment followed stratification for gender and earlier course examination performance. Expert validation of PBL curricular components and noted differences in discussion structure and information resources verified curriculum distinctiveness. Main outcome measures were pre- and post-Cognitive Behavior Survey scores for memorization, reflection, and positive learning experience scales, unit and course evaluations and unit examination scores. Students in problem-based modules demonstrated greater gains in reflective thinking with stable memorization, suggesting improved critical thinking skills. Tenets that problem-based learning promotes knowledge retention and provides a more positive learning experience were not upheld. Knowledge acquisition was not hindered by a problem-based approach. We conclude that gains in reflective thinking and evidence of increased self-directed learning argue for inclusion of PBL in dietetics curricula and that a problem-based education will help dietitians successfully respond to professional development needs.     

Residency performance of graduates from a problem-based and a conventional curriculum

Performance of 130 graduates in residency from a community-oriented, problem-based medical curriculum, and from a parallel, conventional track, were compared on eight dimensions: knowledge, communication with patients, independent learning ability, teamwork, patient education, critical thinking ability, attention to health care costs, and self-assessment. Ratings were obtained from three evaluators: a doctor-supervisor, a nurse and the resident him/herself. The study was undertaken to identify differences between graduates from the two curricular tracks. Differences were observed in the areas of health care costs (supervisors) and communication with patients (residents), and a trend was observed in patient education (supervisors) and knowledge (nurses), The outcomes of the study are discussed in light of the literature on residency performance, and in terms of the educational experiences that characterize the two medical curricula.     

A factor analytic study of clinical competence in undergraduate psychiatry

This study used factor analysis to define the components of clinical competence of medical students during their undergraduate psychiatric training. Four factors were defined; factor 1 related to cognitive and psychological problem-solving; factor 2 tapped the interpersonal and observational skills students showed with patients; factor 3 was characterized by knowledge in the examination setting, and factor 4 related to students' capacity to demonstrate their ability in an interpersonal setting. These are similar to the component skills of clinical competence demonstrated by students in other areas of the medical curriculum. They also correspond to the skills which Walton (1986) has suggested should be focused upon in undergraduate psychiatric education.     

A framework for developing excellence as a clinical educator

The current emphasis on providing quality undergraduate and postgraduate medical education has focused attention on the educational responsibilities of all doctors. There is a greater awareness of the need to train doctors as educators and courses have been set up to satisfy this need. Some courses, such as those on how to conduct appraisal, are specific to one task facing a medical educator. Other courses take a broader view and relate educational theory to practice. In this paper we describe an outcome-based approach in which competence in teaching is defined in terms of 12 learning outcomes. The framework provides a holistic approach to the roles of the teacher and supports the professionalism of teaching. Such a framework provides the basis for the development of a curriculum for teaching excellence. It helps to define important competences for different categories of teachers, communicate the areas to be addressed in a course, identify gaps in course provision, evaluate courses, assist in staff planning and allow individuals to assess their personal learning needs. The framework is presented to encourage wider debate.     

Preparing doctors for tomorrow: information management as a theme in undergraduate medical education

The evolving nature of medical knowledge and technology requires that the practitioners of tomorrow be able to develop practice management and computer skills in order to enhance quality patient care, ongoing education, and research. The paper describes how the discipline of medical informatics can be integrated into an undergraduate medical curriculum, not as a course or series of courses but as a repeated theme throughout the 3-year system-based curriculum. Recommendations specific to integrating medical informatics into an undergraduate curriculum are outlined with respect to: (1) content; (2) content organization; (3) management; and (4) evaluation. Six areas of information and computer management applications are discussed. These are computer-assisted learning, retrieving and organizing information from computerised databases, the application of medical informatics tools to the critical appraisal of literature and associated statistical software packages, hospital- and office-based information systems, and electronic communications. Medical education has a history of resistance to change. Reference to guidelines and experiences of others who have negotiated information management and medical informatics changes into medical school environments can therefore be helpful. It is in this context that this paper is presented.     

Patients as teachers: a qualitative study of patients'' views on their role in a community-based undergraduate project

OBJECTIVES: Patients have been used in clinical medical education for many years with, traditionally, a relatively passive role. Following the General Medical Council recommendations for curricular change and the development of more community-based teaching, 'ordinary patients' in the community are increasingly being partnered with undergraduate students for particular projects. Very little research has been undertaken on patients' perceptions of this role. DESIGN: Semi-structured interviews were carried out with 20 people to explore the views of patients taking part in a community-based undergraduate medical student project (the 'patient study') at Newcastle Medical School about their role as teachers of medical students, what they felt they had gained from participating, any problems or concerns and suggestions for change or improvement. SETTING: Newcastle Medical School, UK. SUBJECTS: Second-year medical students. RESULTS: Two major themes emerged. First, patients saw themselves in active roles as teachers: as experts in their medical condition; as exemplars of their condition; and as facilitators of the development of students' professional skills and attitudes. Secondly, patients felt they had benefited from participation, through talking about their problems; learning more about themselves; the satisfaction of helping; and from receiving gifts. In addition, a number of other issues were identified including interpersonal dynamics, gender and ethnic differences, inadequate briefing of participants and whether such community-based patient involvement might, in some situations, be felt to be exploitative. CONCLUSIONS: The study has shown that patients see themselves clearly as having specific contributions to make to medical students' education and training. This has implications for the further development of community-based teaching.     

Elaborated learning in undergraduate medical education

Southampton Medical School holds its major examination of basic knowledge after rather than before students enter their first clinical attachments. An interview survey investigated its educational effects, and found that students adopt one of four revision approaches. The most successful, not just in terms of examination grade but more particularly in students' subsequent ability to retrieve and use the knowledge gained, occurred when students related their preclinical revision to their clinical experiences. One of these approaches, an elaboration of knowledge, is considered to be essential for effective clinical thinking yet is probably rare elsewhere in medical education since it appears to be a consequence of a particular curricular arrangement. An explanation is given in terms of current thinking in cognitive psychology, and this challenges the theoretical assumptions on which other research in medical education has been uncritically based. Some implications for medical education and further research are discussed.     

A study of critical reflection in health professional education: ‘learning where others are coming from’

A dominant focus of clinical education for health professional students is experiential learning through an apprentice model where students are exposed to a range of clinical scenarios and conditions through observation initially, and then through supervised clinical practice. However experiential learning may not be enough to meet the need for health professionals to be flexible, self-aware and understanding of alternative perspectives or ‘where other people are coming from.’ Critical reflection skills are recognised as a way of thinking and a process for analysing practice, that enables learning from, and redeveloping professional practice in an ongoing way. This paper describes and examines the effect of a three hour per week, six week critical reflection program, grounded in knowledge paradigms of postmodernism, reflexivity and critical theory, on third year undergraduate physiotherapy students’ experience of their first clinical placements. The theoretical basis of the program provides a potential bridge with which to link and broaden the established framework of clinical reasoning theories. Within the program, students’ critical reflection discourse focused on notions of power, hierarchies, connecting with others and relationships. Their feedback about the effects of the program highlighted themes of validation and sharing; a break in clinical performance and a broadening of their spheres of knowledge. These themes resonated with students’ overall experiences of learning in clinical placements and provide some evidence for the inclusion of critical reflection as a valid and worthwhile component of early clinical education.     

Medical students' perceptions of identity in communication skills training: a qualitative study

Objectives  Communication skills training in undergraduate medical education is considered to play an important role in medical students' formation of their professional identity. This qualitative study explores Year 1 students' perceptions of their identities when practising communication skills with real patients.
Methods  A total of 23 individual semi-structured interviews and two focus group discussions were conducted with 10 students during their first year of communication skills training. All interviews and discussions were audio-recorded, transcribed and analysed for emergent themes relating to identity.
Results  Students struggled to communicate professionally with patients because of a lack of clinical knowledge and skills. Consequently, students enacted other identities, yet patients perceived them differently, causing conversational ambiguities.
Discussion  Students' perceptions challenge educational goals, suggesting that there is limited potential for the formation of professional identity through early training. Teacher-doctors must acknowledge how students' low levels of clinical competence and patients' behaviour complicate students' identity formation.     

The accountability of clinical education: its definition and assessment

BACKGROUND: Medical education is not exempt from increasing societal expectations of accountability. Competition for financial resources requires medical educators to demonstrate cost-effective educational practice; health care practitioners, the products of medical education programmes, must meet increasing standards of professionalism; the culture of evidence-based medicine demands an evaluation of the effect educational programmes have on health care and service delivery. Educators cannot demonstrate that graduates possess the required attributes, or that their programmes have the desired impact on health care without appropriate assessment tools and measures of outcome. OBJECTIVE: To determine to what extent currently available assessment approaches can measure potentially relevant medical education outcomes addressing practitioner performance, health care delivery and population health, in order to highlight areas in need of research and development. METHODS: Illustrative publications about desirable professional behaviour were synthesized to obtain examples of required competencies and health outcomes. A MEDLINE search for available assessment tools and measures of health outcome was performed. RESULTS: There are extensive tools for assessing clinical skills and knowledge. Some work has been done on the use of professional judgement for assessing professional behaviours; scholarship; and multiprofessional team working; but much more is needed. Very little literature exists on assessing group attributes of professionals, such as clinical governance, evidence-based practice and workforce allocation, and even less on examining individual patient or population health indices. CONCLUSIONS: The challenge facing medical educators is to develop new tools, many of which will rely on professional judgement, for assessing these broader competencies and outcomes.     

Patient-centred medicine through student-centred teaching: a student perspective on the key impacts of community- based learning in undergraduate medical education

CONTEXT: The UK General Medical Council has proposed that increased use of community settings is essential to enhancement of medical education. However, such curriculum developments have been directed by educationalists and clinical faculty; there is to date little to show whether student perspectives accord with such expectations. AIM: To examine student views on whether community-based learning during a UK undergraduate medical education course results in new learning in the areas expected, and to elucidate any process factors which enhance attainment of learning objectives. METHOD: Nominal group technique, to develop consensus on important learning outcomes and process factors, and questionnaire survey, developed from the views of the nominal groups. RESULTS: 89 students participated (response rate 70% for the nominal groups, and 88% for questionnaire). Students perceived increased learning in many of the areas expected. In particular, students reported significant learning from: witnessing the impact of a longer term and more personal relationship with patients; the visible impact of social environment on health; the importance of dealing with people rather than diseases, and the use of the whole team for care. In addition, they emphasized that tutor, staff and patient enthusiasm for student presence and learning greatly enhanced the student learning experience. CONCLUSIONS: Community settings appear to achieve the expected attitudinal adaptation of students. The role of the committed tutor and team is seen as pivotal to learning. The conclusions support an increased emphasis in contemporary medical education and related research activity on the key impact of relationships in the learning environment.     

A new vision for distance learning and continuing medical education

Increasing demands on continuing medical education (CME) are taking place at a time of significant developments in educational thinking and new learning technologies. Such developments allow today's CME providers to better meet the CRISIS criteria for effective continuing education: convenience, relevance, individualization, self-assessment, independent learning, and a systematic approach. The International Virtual Medical School (IVIMEDS) provides a case study that illustrates how rapid growth of the Internet and e-learning can alter undergraduate education and has the potential to alter the nature of CME. Key components are a bank of reusable learning objects, a virtual practice with virtual patients, a learning-outcomes framework, and self-assessment instruments. Learning is facilitated by a curriculum map, guided-learning resources, "ask-the-expert" opportunities, and collaborative or peer-to-peer learning. The educational philosophy is "just-for-you" learning (learning customized to the content, educational strategy, and distribution needs of the individual physician) and "just-in-time" learning (learning resources available to physicians when they are required). Implications of the new learning technologies are profound. E-learning provides a bridge between the cutting edge of education and training and outdated procedures embedded in institutions and professional organizations. There are important implications, too, for globalization in medical education, for multiprofessional education, and for the continuum of education from undergraduate to postgraduate and continuing education.     

Diagnostic ability of medical students in relation to their learning characteristics and preclinical background

Is the diagnostic ability of medical students — as appraised by the Diagnostic Thinking Inventory (DTI) — influenced by the learners’ characteristics, or the way they acquired basic knowledge? This question was explored in a 4-year consecutive sampling of clinical clerkship students. DTI inventory scores (flexibility in thinking and structure in memory), learners’ characteristics (learning style, self-confidence as a learner, and motivation to learn), together with knowledge scores (grade-point average and problem-solving test) were measured and analysed for their relationships and the differences between groups. Results revealed that higher scores of the DTI measures were associated with students’ high self-confidence, high motivation to learn, and abstract learning types. Correlation coefficients showed significant relationships between the DTI scores and both knowledge measures. In addition, t-tests showed that students with an integrated teaching background and problem-based learning (PBL) experience obtained significantly higher scores for structure in memory. The findings suggest that the inventory scores are sensitive to both cognitive and non-cognitive factors. The inventory may be useful in detecting subtle influences on diagnostic ability differentiation in medical students.     

Active and problem-based learning: two years'' experience in physiology at the Medical School of the University of Barcelona

Traditional educational methods are used in most medical schools. The introduction of new methods including active and problem-solving learning in traditional medical schools is difficult. The aims of this experiment were: (1) to introduce a self-learning system with a problem-solving approach in physiology; (2) to promote active student participation; (3) to introduce early clinical exposure; (4) to evaluate the response of the students to this experiment; and (5) to evaluate the feasibility and usefulness of a self-learning and problem-solving approach in only one discipline. Our experience has shown that it is possible to change the learning system in a traditional medical school, with good acceptance by the students and with a high level of satisfaction on the part of the teachers.