Approaches to medical student remediation after a comprehensive clinical skills examination

OBJECTIVE: Most US medical schools conduct comprehensive clinical skills assessments during Years 3 and 4. This study explores strategies used to identify and remediate students who perform poorly on these assessments. METHODS: In the academic year 2005-06, we conducted 33 semi-structured interviews with individuals responsible for standard setting in and remediation after their schools' comprehensive clinical skills assessments. We coded interviews to identify major themes. RESULTS: Prior to remediation, some schools employed a 'verification' step to ensure the accuracy of the failing score or need for remediation. Participants described a remediation process that included some or all of 3 steps. Firstly, students' specific learning deficits were diagnosed. Next, students participated in remedial activities such as performance review sessions or practice with standardised or actual patients. Lastly, students were re-tested, usually with a shorter, more formative examination. All participants reported using a diagnostic step, most offered or required remedial activities and many re-tested, although schools varied in the emphasis placed on each step. Many participants cited the individualised attention students received from remediation faculty staff as a strength of their approach, although they raised concerns about the substantial time demands placed on remediation faculty. Most respondents reported some dissatisfaction with their school's remediation process, particularly uncertainty about efficacy or rigour. CONCLUSIONS: Schools vary in the intensity and scope of remediation offered to students who perform poorly on clinical skills assessments. Although many schools invest significant resources in remediation, the effect of these efforts on students' subsequent clinical performance is unknown.     

Current status of teaching on spirituality in UK medical schools

OBJECTIVE: To investigate the current status of teaching on spirituality in medicine in UK medical schools and to establish if and how medical schools are preparing future doctors to identify patients' spiritual needs. METHODS: We carried out a national questionnaire survey using a 2-part questionnaire. Section A contained questions relating to the quantity of teaching on spirituality and the topics covered. Section B contained questions relating to teaching on alternative health practices. Medical educators from each of the 32 medical schools in the UK were invited to participate. RESULTS: A response rate of 53% (n = 17) was achieved. A total of 59% (n = 10) of respondents stated that there is teaching on spirituality in medicine in their curricula. On extrapolation, at least 31% and a maximum of 78% of UK medical schools currently provide some form of teaching on spirituality. Of the respondents that teach spirituality, 50% (n = 5) stated that their schools include compulsory teaching on spirituality in medicine, 80% (n = 8) include optional components, and 88% stated that teaching on complementary and alternative medicine is included in the curriculum. CONCLUSIONS: Although 59% (n = 10) of respondent medical schools (the actual UK figure lies between 31% and 78%) currently provide some form of teaching on spirituality, there is significant room for improvement. There is little uniformity between medical schools with regard to content, form, amount or type of staff member delivering the teaching. It would be beneficial to introduce a standardised curriculum on spirituality across all UK medical schools.     

Students' perceptions of race, ethnicity and culture at two UK medical schools: a qualitative study

CONTEXT: Globalisation has profoundly affected health care by increasing the diversity of clinicians and their patients. Worldwide, medical schools highlight the need for students to understand and show respect for patients and peers of different ethnicities. Yet a sound theoretical approach and robust methods for learning about cultural awareness are lacking. The reasons for this are unclear. OBJECTIVE: To explore Year 2 medical students' understanding of the concepts of race, ethnicity and culture. METHODS: This study was set in 2 universities in the north of England. The student population of each was of a similar ethnic mix but the universities differed in terms of local demography (a wide patient ethnic mix versus a predominantly White patient population with experience of social deprivation) and curricula (a curriculum involving problem-based learning and paper-based cases versus a curriculum involving early contact with patients). Participants comprised 49 Year 2 medical students (mean age 20.8 years), 40% of whom came from ethnic minority groups. Seven focus groups were held across the 2 universities to explore students' understanding of cultural awareness. Students were asked to discuss the terms 'race', 'ethnicity', 'culture' and 'cultural diversity'. Interviews were transcribed and analysed qualitatively using grounded theory. Themes were identified and validated by an independent researcher. RESULTS: Four overarching themes emerged: 'White fears' at discussing race-related issues; ethnic minority discomfort at being viewed as 'different'; difficulties in relating to professional boundaries, and barriers against talking about race beyond legitimate disease-related discourse. CONCLUSIONS: For students, discussion of race beyond the confines of medical discourse was problematic. If students are to develop professional holistic values towards patient care, they need more support in understanding their own personal values and uncertainties.     

Using borderline methods to compare passing standards for OSCEs at graduation across three medical schools

CONTEXT: Medical schools in the UK set their own graduating examinations and pass marks. In a previous study we examined the equivalence of passing standards using the Angoff standard-setting method. To address the limitation this imposed on that work, we undertook further research using a standard-setting method specifically designed for objective structured clinical examinations (OSCEs). METHODS: Six OSCE stations were incorporated into the graduating examinations of 3 of the medical schools that took part in the previous study. The borderline group method (BGM) or borderline regression method (BRM) was used to derive the pass marks for all stations in the OSCE. We compared passing standards at the 3 schools. We also compared the results within the schools with their previously generated Angoff pass marks. RESULTS: The pass marks derived using the BGM or BRM were consistent across 2 of the 3 schools, whereas the third school generated pass marks which were (with a single exception) much lower. Within-school comparisons of pass marks revealed that in 2 schools the pass marks generally did not significantly differ using either method, but for 1 school the Angoff mark was consistently and significantly lower than the BRM. DISCUSSION: The pass marks set using the BGM or BRM were more consistent across 2 of the 3 medical schools than pass marks set using the Angoff method. However, 1 medical school set significantly different pass marks from the other 2 schools. Although this study is small, we conclude that passing standards at different medical schools cannot be guaranteed to be equivalent.     

Overview of accreditation of undergraduate medical education programmes worldwide

Context  There is significant variation in the structure and quality of undergraduate medical education around the world. Accreditation processes can encourage institutional improvement and help promote high-quality education experiences.
Methods  To investigate the overseeing of medical education from an international perspective, the Foundation for Advancement of International Medical Education and Research (FAIMER^®) has developed, and continues to update, the Directory of Organizations that Recognize/Accredit Medical Schools (DORA). The directory includes information on the presence of national accrediting bodies and related data. Medical education accreditation information was pooled by World Health Organization (WHO) regions.
Results  Although over half of all countries with medical schools indicate that they have a national process for accrediting medical education programmes, the nature of the various authorities and levels of enforcement vary considerably.
Discussion  Despite global trends indicating an increasing focus on the quality of education programmes, data linking accreditation processes to the production of more highly skilled doctors and, ultimately, better patient care are lacking. Investigating current accreditation practices is a necessary step for further research. To this end, we will continue to gather data on medical education around the world and will explore opportunities for relating these processes to outcomes.     

Development of a framework of medical undergraduate teaching activities

Context  The need for a comprehensive framework of teaching activities in undergraduate medical education was identified by colleagues involved in teacher training at the University of Edinburgh, UK and Karolinska Institutet, Sweden. Such a framework could be used to develop training programmes for medical teachers, to help experienced teachers to reflect upon and communicate with others about their practice, and as a focus for further research on medical teaching.
Methods  A provisional framework of medical teaching activities and a model illustrating how these activities are situated within the wider context of learning and teaching were developed iteratively using the literature and pilot studies. The provisional framework and model were then methodically tested using journal analysis, brainstorming sessions and focus group sessions with medical teachers and teacher trainers in both institutions. Data gathered from this research were analysed and used to further develop the framework and model.
Results  Many of the provisional teaching activities in the framework were further developed in response to the research data and some new activities were added. Teaching activities seemed to cluster into three domains: 'Facilitating', 'Managing', and 'Learning and Community Building'. Specific tasks were identified relating to planning, administering, resourcing, implementing and evaluating each teaching activity. Participants found the model of learning and teaching helpful and felt it adequately represented the place of teaching activities within the wider context of undergraduate medical education. The framework and model are now being used by the authors in faculty development, undergraduate teaching and further research.     

How undergraduate clinical learning climates differ: a multi-method case study

Context The clinical learning climate affects undergraduate medical students’ behaviour, satisfaction and success. Most studies predominantly describe aspects of the clinical learning climate using quantitative methodologies, such as questionnaires. This study aimed to illuminate medical students’ perceptions of the clinical learning climate, and which factors and their interactions explain differences in clinical learning climates. Methods We carried out a multi‐method case study. Twelve departments of obstetrics and gynaecology distributed the Postgraduate Hospital Educational Environment Measure (PHEEM), a reliable questionnaire measuring the clinical learning environment, among medical students. After analysis (using anova and post hoc tests), 14 medical students from the highest‐ and lowest‐scoring departments participated in semi‐structured interviews. We analysed the transcribed recordings using a content analysis approach. Researchers agreed on coding and an expert group reached consensus on the themes of the analysis. Results We found a significant difference between departments in PHEEM scores. The interviews indicated that department and medical student characteristics determine the clinical learning climate. For departments, ‘legitimacy’, ‘clerkship arrangements’ and ‘focus on personal development’ were the main themes. For medical students, ‘initial initiatives’, ‘continuing development’ and ‘clerkship fatigue’ were the principal themes. The amount and nature of participation played a central role in all themes. Conclusions Differences between clinical learning climates appear to be related to differing approaches to participation among departments. Participation depends on characteristics of both departments and students, and the interactions among them. The outcomes give valuable clues to how a favourable clinical learning climate is shaped.     

Team-based learning at ten medical schools: two years later

PURPOSE: In 2003, we described initial use of team-based learning (TBL) at 10 medical schools. The purpose of the present study was to review progress and understand factors affecting the use of TBL at these schools during the subsequent 2 years. METHODS: Representatives from 10 schools evaluated in 2003 were again evaluated in 2005. They were interviewed by members of the Team Based Learning Collaborative using a semistructured interview process. Data were analysed by 2 researchers using the constant comparative method and were triangulated through sharing results with other interviewers at regular intervals to verify conclusions and form consensus. RESULTS: TBL continued to be used in all but 1 school. At the 9 remaining schools, TBL was added to 18 courses, continued to be used in 19 and was discontinued in 13 courses. At some schools, it was discontinued in single courses in lieu of new, longitudinal integration courses in which TBL was a main instructional strategy. Faculty, student, course and institutional factors were associated with changes in TBL use. CONCLUSION: Faculty, administration/curriculum, students and characteristics of specific courses influence ongoing utilisation of TBL. Those who desire to implement TBL would do well to take these factors into account as they plan implementation efforts at their schools.     

Making a difference: researching master's and doctoral research programmes in medical education

CONTEXT: The Association for the Study of Medical Education states that its aim is to improve the quality of medical education. As a consequence, it commissioned through its Education Research Group a small-scale project to explore the quality of the research methods elements in currently available UK master's and doctoral programmes. OBJECTIVE: This study aimed to explore the breadth, depth and diversity of the research methods provision of those programmes currently available to course participants. METHODS: The study comprised a 3-phase approach which utilised: a web-based search of curricula format and content; semi-structured interviews with key informants, and case studies and site visits to conduct documentary analysis of dissertations and in-depth interviews with core personnel. RESULTS: The study revealed wide variation across taught programmes. These discrepancies applied to length of course, requirements for the dissertation in terms of both length and time allowed to complete the study and, crucially, a wide variance in the quality and quantity of the levels of supervision provided for students during this research phase. DISCUSSION: This study raises concerns about the aims and functions of courses offering qualifications in medical education. It identifies a number of obstacles to the development of educational researchers who are skilled in the philosophical underpinnings of research activity or equipped to undertake educational research that is of a quality sufficient to withstand the scrutiny of the authors' scientific and clinical counterparts. We argue that if research into medical education is to thrive, it requires the full commitment of all those who are engaged in teaching the topic and supporting researchers.     

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.     

Anatomical dissection as a teaching method in medical school: a review of the evidence

CONTEXT: Discussions about dissection as a teaching method in gross anatomy are characterised by a lack of objective evidence. METHODS: A search for such evidence in the literature produced 14 relevant papers. These were reviewed for objective data on the effect of cadaver dissection on cognitive learning outcomes. RESULTS: All reviewed studies compared groups of students exposed to different teaching approaches, including active dissection, learning on prosected material, or a combination with computerised teaching aids. Study and course designs varied substantially and student groups compared were not always homogeneous. In all studies, compared learning experiences differed in more than 1 variable, and assessment of anatomical knowledge was not standardised. DISCUSSION: It is difficult to interpret and generalise from the results of the reviewed studies. Considering the bias that must be assumed for teachers who develop new course designs and compare these with traditional ones, the review shows a slight advantage for traditional dissection over prosection. CONCLUSIONS: More sophisticated research designs may be necessary to solve the general problem of the small measurable impact of educational interventions and to come to scientifically sound conclusions about the best way to teach gross anatomy. Such research will have to include sufficient sample sizes, the use of validated assessment instruments, and a discussion of the educational significance of measured differences. More educational research in anatomy is necessary to counterbalance emotional arguments about dissection with scientific evidence. Anatomical knowledge is too important to future doctors to leave its teaching to the educational fashion of the day.     

The teaching of professional attitudes within UK medical schools: Reported difficulties and good practice

INTRODUCTION: The demonstration of appropriate attitudinal behaviour is crucial in the professional development of doctors. This study explores the experiences of UK medical schools in developing and assessing the behaviour associated with the attitudes of undergraduate medical students. METHODS: A qualitative in-depth interview study was based on a questionnaire survey of all UK medical schools. Six heads of medical schools or their nominated representatives were interviewed. Outcome measures were the perceptions and experiences of developing and assessing appropriate attitudes and behaviour in their undergraduate students. RESULTS: Aspects of the hidden curriculum, especially the negative role modelling encountered during clinical practice, were seen to undermine the attitudinal messages of the formal curriculum. Some participants believed that students could still qualify as doctors despite having inappropriate attitudes or behaviour. Others felt certain that this was now unlikely in their school, and this confidence seemed to be backed up with the knowledge that strategies, systems and structures were in place to detect and act upon poor behaviour. DISCUSSION: The conviction that it is right to assess students on their attitudinal behaviour does not yet appear to be held consistently across all schools and we suggest that this may reflect some fundamental tensions arising from differing views about the essential elements of good medical practice, tensions that are also shaping the hidden curriculum.     

How interdisciplinary teams can create multi-disciplinary education: the interplay between team processes and educational quality

CONTEXT: Many undergraduate medical education programmes offer integrated multi-disciplinary courses, which are generally developed by a team of teachers from different disciplines. Research has shown that multi-disciplinary teams may encounter problems, which can be detrimental to productive co-operation, which in turn may diminish educational quality. Because we expected that charting these problems might yield suggestions for addressing them, we examined the relationships between team diversity, team processes and course quality. METHODS: We administered a questionnaire to participants from 21 interdisciplinary teams from 1 Dutch and 1 German medical school, both of which were reforming their curriculum. An adapted questionnaire on team learning behaviours, which had been validated in business contexts, was used to collect data on team processes, team learning behaviours and diversity within teams. We examined the relationship between the team factors and educational quality measures of the courses designed by the teams. RESULTS: A total of 84 teachers (60%) completed the questionnaire. Bivariate correlation analysis showed that several aspects of diversity, conflict, working climate and learning behaviour were correlated with course quality. CONCLUSIONS: The negative effects of the diversity measures, notably, value diversity, on other team processes and course quality and the positive association between psychological safety and team learning suggest that educational quality might be improved by enhancing the functioning of multi-disciplinary teams responsible for course development. The relationship between team processes and educational quality should be studied among larger study populations. Student ratings should also be considered in measuring educational quality.     

Instructional methods and cognitive and learning styles in web-based learning: report of two randomised trials

CONTEXT: Adapting web-based (WB) instruction to learners' individual differences may enhance learning. Objectives This study aimed to investigate aptitude-treatment interactions between learning and cognitive styles and WB instructional methods. METHODS: We carried out a factorial, randomised, controlled, crossover, post-test-only trial involving 89 internal medicine residents, family practice residents and medical students at 2 US medical schools. Parallel versions of a WB course in complementary medicine used either active or reflective questions and different end-of-module review activities ('create and study a summary table' or 'study an instructor-created table'). Participants were matched or mismatched to question type based on active or reflective learning style. Participants used each review activity for 1 course module (crossover design). Outcome measurements included the Index of Learning Styles, the Cognitive Styles Analysis test, knowledge post-test, course rating and preference. RESULTS: Post-test scores were similar for matched (mean +/- standard error of the mean 77.4 +/- 1.7) and mismatched (76.9 +/- 1.7) learners (95% confidence interval [CI] for difference - 4.3 to 5.2l, P = 0.84), as were course ratings (P = 0.16). Post-test scores did not differ between active-type questions (77.1 +/- 2.1) and reflective-type questions (77.2 +/- 1.4; P = 0.97). Post-test scores correlated with course ratings (r = 0.45). There was no difference in post-test subscores for modules completed using the 'construct table' format (78.1 +/- 1.4) or the 'table provided' format (76.1 +/- 1.4; CI - 1.1 to 5.0, P = 0.21), and wholist and analytic styles had no interaction (P = 0.75) or main effect (P = 0.18). There was no association between activity preference and wholist or analytic scores (P = 0.37). CONCLUSIONS: Cognitive and learning styles had no apparent influence on learning outcomes. There were no differences in outcome between these instructional methods.     

Can medical students from two cultures learn effectively from a shared web‐based learning environment?

OBJECTIVE: This study aimed to establish whether medical students from 2 different cultures can learn effectively from a shared web-based learning environment. METHODS: Students from the College of Medicine, Edinburgh, UK and the Medical School, Gifu, Japan shared 2 weeks of teaching and learning in clinical genetics, using problem-based learning in a web-based application (WBA). Questions about language, time zone, agreement about the curriculum (learning outcomes, tutor activity and assessment) and specific pedagogical issues about the educational effectiveness of students' learning were considered. RESULTS AND CONCLUSIONS: The evidence indicates that a shared WBA is practical where the learning outcomes and problem scenarios are common and students are fluent in the same language. Problem-based learning transfers itself best to online discussion boards when the numbers in the group are 16 or more. Students do not use the WBA as a primary source of resource material, and they augment the discussion boards with face-to-face meetings with peers and tutors.     

Personality traits and types predict medical school stress: a six-year longitudinal and nationwide study

OBJECTIVES: Personality types (combinations of traits) that take into account the interplay between traits give a more detailed picture of an individual's character than do single traits. This study examines whether both personality types and traits predict stress during medical school training. METHODS: We surveyed Norwegian medical students (n = 421) 1 month after they began medical school (T1), at the mid-point of undergraduate Year 3 (T2), and at the end of undergraduate Year 6 (T3). A total of 236 medical students (56%) responded at all time-points. They were categorised according to Torgersen's personality typology by their combination of high and low scores on the 'Big Three' personality traits of extroversion, neuroticism and conscientiousness. We studied the effects of both personality types (spectator, insecure, sceptic, brooder, hedonist, impulsive, entrepreneur and complicated) and traits on stress during medical school. RESULTS: There was a higher level of stress among female students. The traits of neuroticism (P = 0.002) and conscientiousness (P = 0.03) were independent predictors of stress, whereas female gender was absorbed by neuroticism in the multivariate model. When controlled for age and gender, 'brooders' (low extroversion, high neuroticism, high conscientiousness) were at risk of experiencing more stress (P = 0.02), whereas 'hedonists' (high extroversion, low neuroticism, low conscientiousness) were more protected against stress (P = 0.001). CONCLUSIONS: This is the first study to show that a specific combination of personality traits can predict medical school stress. The combination of high neuroticism and high conscientiousness is considered to be particularly high risk.     

The need for teaching in medical audit: a survey in one medical school

Summary: Summary. A questionnaire survey was carried out among senior clinical teachers at Newcastle upon Tyne Medical School, UK about their current practice and attitudes toward the teaching of medical audit in the undergraduate curriculum. A response rate of 88% was achieved. Less than a fifth of respondents provided such teaching, but the majority were in favour of seeing the topic introduced. A variety of teaching methods were used, and feedback from students was generally favourable. A number of concerns were expressed, including the problem of curriculum overload, the timing of the teaching, and the need to ensure that the learning was experiential with a minimum of theoretical teaching. Those who were in favour of introducing such teaching, or who were unsure, were also concerned about pressures on curricular time, but some felt in addition that the topic was more appropriately a postgraduate one. A short attitude scale demonstrated a skew towards favourable attitudes among the whole group. The implications of the survey for teaching about audit and quality are discussed.     

Origin bias of test items compromises the validity and fairness of curriculum comparisons

OBJECTIVE: To determine whether items of progress tests used for inter-curriculum comparison favour students from the medical school where the items were produced (i.e. whether the origin bias of test items is a potential confounder in comparisons between curricula). METHODS: We investigated scores of students from different schools on subtests consisting of progress test items constructed by authors from the different schools. In a cross-institutional collaboration between 3 medical schools, progress tests are jointly constructed and simultaneously administered to all students at the 3 schools. Test score data for 6 consecutive progress tests were investigated. Participants consisted of approximately 5000 undergraduate medical students from 3 medical schools. The main outcome measure was the difference between the scores on subtests of items constructed by authors from 2 of the collaborating schools (subtest difference score). RESULTS: The subtest difference scores showed that students obtained better results on items produced at their own schools. This effect was more pronounced in Years 2-5 of the curriculum than in Year 1, and diminished in Year 6. CONCLUSIONS: Progress test items were subject to origin bias. As a consequence, all participating schools should contribute equal numbers of test items if tests are to be used for valid and fair inter-curriculum comparisons.     

A survey of clinical teaching fellowships in UK medical schools

CONTEXT: Undergraduate medical education in the UK has changed considerably over the last decade. One development has involved the creation of teaching-specific posts for junior doctors by medical schools. These posts are generally termed 'clinical teaching fellowships', but it is not known how many of them exist, or whether they are similar in terms of educational activities, professional development, and research and clinical experience opportunities. METHODS: Teaching deans in all UK medical schools were sent a questionnaire relating to clinical teaching fellowships, and were asked to distribute a second set of different questionnaires to their clinical teaching fellows, which were to be returned to the authors separately. RESULTS: A total of 28 deans and 46 fellows responded. Fifteen medical schools had clinical teaching fellows and there appeared to be a total of 77 such posts in the UK. There was little uniformity in the activities undertaken within the posts. Deans who employed clinical teaching fellows were unanimously positive regarding the posts. Fellows were generally positive but expressed reservations relating to approval for postgraduate training, career development, deterioration in clinical skills, financial disincentives, credibility within one's own specialty, and provision of training and support. CONCLUSIONS: Clinical teaching fellow posts are generally enjoyed by fellows and valued by deans. Fellows carry out differing duties and their training in medical education is variable. The posts can be unstructured and may lack credibility to doctors outside medical education. Providing specific structured training in medical education, recognised at a national level, would help deal with these concerns.