Teaching support in the behavioural sciences for non-English speaking background medical undergraduates

INTRODUCTION: This paper reports on a teaching strategy designed to support first year undergraduate medical students from non-English speaking backgrounds in a behavioural science course taught at an Australian university. METHOD: The strategy is described, as is the language profile of students from two successive cohorts who participated in the teaching programme. The effectiveness of the intervention in improving students' academic performance is explored, as gauged by summative assessment and student perceptions. CONCLUSIONS: Findings suggest that students disadvantaged by difficulties with language and/or knowledge of Australian culture were able to perform at least as well as other students on a number of summative criteria. Non-English speaking background students perceived the behavioural science course to be difficult, and indicated that they found the teaching support offered to them to be useful. The methodological difficulties and limitations involved in the evaluation of a teaching programme such as this are discussed and the conclusions that can be validly drawn are considered.     

Experiential learning improves the learning and retention of endotracheal intubation

Context  Simulators provide an effective platform for the learning of clinical motor skills such as endotracheal intubation, although the optimal learning technique remains unidentified. We hypothesised that, for novices, experiential learning would improve the learning and retention of endotracheal intubation compared with guided learning.
Methods  Year 4 medical students were randomised to either guided or experiential learning. Students in the guided group were taught using the conventional step-by-step technique. Students in the experiential group had to work out the correct technique for intubation on their own. Both groups had further opportunities to intubate manikins and patients during their postings. The students were recalled 3, 6, 9 and 12 months later, and their intubation skills assessed in four major categories: equipment preparation; intubation technique; successful intubation, and placement confirmation.
Results  A total of 210 students (107 guided, 103 experiential) participated in the study. At 3 months, 64.5% of the students in the experiential group successfully intubated the manikin, compared with 36.9% in the guided group ( P  < 0.001). The experiential group also had higher overall scores, signifying quality of intubation attempts, at 3 months (79% versus 70%; P  < 0.001). Success rates and overall scores for both groups were comparable at 6 and 9 months, but were better in the experiential group at 12 months. Success rates improved with time, reaching 86% at 12 months.
Conclusions  Novices learned and retained the skill of endotracheal intubation better with experiential learning. This study suggests that experiential learning should be adopted for the teaching of endotracheal intubation and that refresher tuition at 3-monthly intervals will prevent the decay of this skill in infrequent users.     

Use of scheme-based problem solving: an evaluation of the implementation and utilization of schemes in a clinical presentation curriculum

CONTEXT: The University of Calgary has implemented a new curriculum which is organized according to 120 ways in which patients may present to a physician. Students are taught scheme-based problem solving rather than the more typical hypothetico-deductive or search and scan approach to problem resolution. OBJECTIVE: This study sought to determine the extent to which faculty and students were implementing and utilizing scheme-based problem solving. METHOD: All classes taught within the new clinical presentation curriculum were surveyed at the year end. Participants included four classes of first-year students and three classes of second-year students. Using a 5-point scale, students responded to survey items regarding scheme implementation and utilization. RESULTS: Data were analysed using MANOVA (multivariate analysis of variance) and revealed significant differences among classes in both first- and second-year students. Increments in scheme implementation and utilization by instructors and students were observed, although instructors' utilization of schemes lagged behind that of students. A levelling effect to the benefits of schemes for problem solving was also evident. First-year students reported schemes to be very useful for learning and organizing new information. CONCLUSION: Although it has taken time to implement curriculum change, the student response to schemes has been favourable. Faculty development and further generation of pictorial/spatial representations for all schemes, to ensure that all clinical presentations provide pathways that students can use for both learning and problem solving are recommended. Whether students who utilize schemes are more successful problem solvers is not yet known but will be the subject of study as soon as scheme delivery is predominant.     

Structured packs for independent learning: a comparison of learning outcome and acceptability with conventional teaching

OBJECTIVES: The GMC recommends that students become independent learners, while tutor time is an increasingly precious resource. A set of structured learning materials requiring students to undertake and reflect on practical tasks in five learning areas was developed. DESIGN: The study used a randomized control trial to evaluate the effectiveness of using these structured learning materials in place of conventional teaching for 228 third-year undergraduate students and 55 teachers, on both hospital and community based medical and general practice firms. Evaluation involved assessing student performance on an examination question and a writing task, together with a student and tutor satisfaction questionnaire. SETTING: King's College School of Medicine and Dentistry, London. SUBJECTS: Third-year medical (first-year clinical) undergraduates. RESULTS: No significant difference in learning outcome was found for students on community- and hospital-based medical and general practice firms between students who had used the structured materials and those who had had conventional teaching on the same topic. The packs were acceptable to tutors and students. CONCLUSIONS: Such resources represent a mid-point between formal didactic teaching and self-directed learning. They may be particularly suitable for promoting independent learning for students on traditional medical courses. They offer an appropriate way to cover certain topics in the clinical curriculum and help to protect tutor time for topics which cannot be effectively taught in other ways.     

Trialling a new way to learn clinical skills: systematic clinical appraisal and learning

AIM: To describe and evaluate the effectiveness of a new method of teaching clinical skills designed to increase students' active and self-directed learning as well as tutor feedback. METHODS: A total of 22 consenting Year 4 medical students undertaking general practice and general surgery clinical experience were involved in a pre- and post-test research design. In the initial period of the study, students were taught clinical skills in a traditional manner. In the second phase a clinical teaching strategy called systematic clinical appraisal and learning (SCAL) was utilised. This learning strategy involved active and self-directed learning, holistic care and immediate feedback. Students independently saw a patient and were asked to make judgements about the patient's potential diagnosis, tests required, management, psychosocial needs, preventive health requirements, and any ethical problems. These judgements were then compared with those of the clinical supervisor, who saw the same patient independently. Students recorded details for each consultation. Comparisons were made of the two study periods to examine whether the use of SCAL increased the number of students' independent judgements, perceived student learning, tutor feedback and self-directed learning. RESULTS: During the SCAL learning period, students reported making a greater number of statistically significant independent judgements, and receiving significantly increased tutor feedback in both general practice and general surgery. The number of learning goals set by students was not found to differ between the two periods in surgery but significantly increased in general practice in the SCAL period. Students' perceptions of their learning significantly increased in the SCAL period in surgery but not in general practice. During the traditional learning period in both settings, there was limited student decision-making about most aspects of care, but particularly those relating to prevention, psychosocial issues and ethics. CONCLUSIONS: The SCAL approach appears to offer some advantages over traditional clinical skills teaching. It appears to encourage active and independent decision-making, and to increase tutor feedback. Further exploration of the approach appears warranted.     

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.     

Patient simulation for training basic and advanced clinical skills

Introduction  Patient simulators are increasingly used in the education and training of healthcare professionals. This paper describes the history of human patient simulator development, the features of contemporary simulators, the acquisition of basic and advanced clinical skills using patient simulators, and the benefits, cost, limitations and effectiveness of this innovative learning modality.
Simulator development  The development of human patient simulators began in the late 1960s, and accelerated in the late 1980s and early 1990s. Several simulator systems are now professionally manufactured, commercially available, and used at hundreds of medical centres, universities and colleges in the USA and throughout the world. Contemporary patient simulators have many clinical features, and look and respond to interventions with ever-increasing degrees of realism because sophisticated physiological and pharmacological models automatically control many features.
Simulator use in medical education  Simulators are used to teach basic skills, such as respiratory physiology and cardiovascular haemodynamics, and advanced clinical skills, e.g. management of difficult airways, tension pneumothorax, pulmonary embolism and shock.
Benefits, costs and limitations  The simulation laboratory offers distinct educational advantages, especially for learning how to recognise and to treat rare, complex, clinical problems. Costs of simulator-based educational programmes include facility, equipment and personnel. Current limitations include clinical realism of the patient manikin and faculty development.     

Medical statistics: content and objectives of a core course for medical students

Summary. British medical school teachers of medical statistics aspire to teach statistical concepts without requiring medical students to undertake every statistical technique in the book. In the typical course of 20–30 hours, about 50 topics are taught, usually requiring the student to perform a technique. In a survey of current practice in 20 courses it is shown that a core syllabus of 36 topics, including 14 techniques to be performed, is feasible for almost all existing courses. Clear student learning objectives now need to be agreed to encapsulate this syllabus.     

Learning together: clinical skills teaching for medical and nursing students

OBJECTIVE: To evaluate the feasibility and effectiveness of shared learning of clinical skills for medical and nursing students at the University of Manchester. DESIGN: Medical and nursing students learned clinical skills in either uniprofessional or multiprofessional groups. These groups rotated through skills stations taught by multiprofessional facilitators. The groups stayed together for a series of 3 sessions held at weekly intervals (an induction meeting followed by 2 3-hour teaching sessions). Both quantitative and qualitative methods were used to evaluate the project. CONTEXT: A total of 113 Year 3 students registered on the Medical (n = 41), Bachelor of Nursing (Honours) (n = 43) or the Diploma for Professional Studies in Nursing (n = 29) courses participated in the project which was set in the clinical skills unit of a teaching hospital. RESULTS: Pre- and post self-evaluation of confidence levels for the taught skills revealed a statistically significant increase for all skills. The primary reason students gave for participation in the project was to learn or consolidate skills. An additional inducement for participation was the opportunity to share knowledge and observations between professional groups. Tutors also evaluated the experience favourably, particularly with regard to small group discussions. They indicated that the programme provided an opportunity to standardise clinical skills teaching. CONCLUSION: Collaborative learning opportunities for nursing and medical students are feasible and add value to the learning experience. Data indicate positive outcomes of learning in multiprofessional groups, comprising increased confidence levels, increased understanding of others' professional roles and personal development.     

An innovative model for teaching and learning clinical procedures

CONTEXT: Performing a clinical procedure requires the integration of technical clinical skills with effective communication skills. However, these skills are often taught separately. OBJECTIVES: To explore the feasibility and benefits of a new conceptual model for integrated skills teaching. : Design A qualitative observation and interview-based study of undergraduate medical students. METHODOLOGY: Medical students performed technical and communication skills in realistic clinical scenarios (urinary catherization and wound closure), using latex models connected to simulated patients (SPs). Procedures were observed, videorecorded and assessed by tutors from an adjoining room. Students received immediate feedback from tutors and SPs, before engaging in a process of individual feedback through private review of their videotapes. Group interviews explored the response of students, SPs and tutors. Data were analysed using standard qualitative techniques. SUBJECTS: Fifty-one undergraduate students were recruited from the Faculty of Medicine, Imperial College, London. RESULTS: The scenarios provided a realistic simulation of two common clinical situations and proved feasible in terms of time, facilities and resources within this institution. Students found the opportunity to integrate communication and technical skills valuable, challenging and an appropriate learning experience. Immediate feedback was especially highly valued. Some students found difficulty integrating technical and communications skills, but benefited from conducting two procedures in the same session. CONCLUSION: The integrated model was feasible and was perceived to be valuable. Benefits include the opportunity to integrate, within a safe environment, skills which are often taught separately. Promoting reflective practice may enable the successful transfer of these integrated skills to other procedures.     

改良式气道管理车在急诊气管插管中的运用

目的评价改良式气道管理车在急诊气道管理中的应用。 方法将80例病例分为A、B两组,每组各40例,未运用改良式气道管理车的定为对照组A组,运用改良式气道管理车的实验组B组,分别记录每个患者气管插管时间,两组进行比较。 结果A组时间为(5.90±1.23)min,B组时间(4.50±0.78)min,两组比较P<0.05,差异有统计学意义,明显B组所用时间较短。 结论运用改良式气道管理车后可视喉镜气管插管准备及操作时间明显缩短,这对抢救有极大的意义。     

Education for practice: the role of practical experience in undergraduate and general clinical training

A questionnaire and interview study in two London medical schools reviewed the undergraduate curricula and house year from the perspectives of graduates one year after qualification. Data from 113 house officers (44%), obtained by questionnaire and interview, showed general satisfaction with training. However, they also saw undergraduate preparation as deficient in exposure to some practical procedures and common conditions, and several difficult communication skills were not taught. Graduates reported that they would have liked more experience as undergraduates in resuscitation, lumbar puncture, inserting nasogastric tubes, endotracheal intubation, and in managing diabetic keto-acidosis, asthmatic attacks, myocardial infarcts and respiratory failure. The purposes of the house year and the articulation between it and the undergraduate years require clarification.     

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.     

Simulated patients and the assessment of medical students' interpersonal skills

While the use of simulated patients for the assessment of medical students' skills is increasing there is little data on whether students perform differently vs real patients. The present study examined this issue using second-year medical students' ability to empathize with simulated and genuine patients. Forty second-year students each conducted two interviews which were audio-recorded and later rated by raters who had achieved a high degree of reliability using the 9-point accurate empathy scale ( Truax, 1967 ). Ten students saw a genuine patient for each interview while ten students saw simulators on both occasions. Of the remaining twenty students, ten saw genuine patients at the first interview and simulated patients at the second session. This order was reversed for the remaining ten students. No significant differences were found in the levels of empathy between students' interaction with genuine or simulated patients. As the students were also unable to discriminate between the two groups of patients it was concluded that simulators represent a viable procedure given the skill to be assessed in the present research and the experience of the students.     

Health promotion projects: skill and attitude learning for medical students

OBJECTIVES: The aim of this health promotion project is to introduce students to appropriate skills and attitudes--as well as knowledge about health promotion strategies and methods. As part of this process, standardized procedures have been established to ensure that the projects are scientifically and ethically appropriate and adequately supervised. This project-centred course introduces the discipline of health promotion to third-year medical students at Monash University. It is aimed at introducing students to the range of health promotion concepts, providing them with experience of health promotion activities and involving them in consideration of the scientific, political and ethical issues arising from doctors' participation in health promotion. DESIGN: As the major learning and assessment component of the unit, students participate in self-selected project groups of three to five students. Each group develops a topic for a health promotion activity in the community, carries out that project and presents the results as a poster as well as a written report. SETTING: Monash University. SUBJECTS: Third-year medical students. RESULTS: Sixty per cent of each student's mark for the unit is based on the project. The posters produced by the project groups are placed on public display in a major teaching hospital for a week at the end of the unit. Public display of the posters helps each student to appreciate the variety of possible health promotion activities, and to appreciate health promotion as a scientific discipline. It also makes the project findings available to the public. CONCLUSIONS: Student evaluation of the project, and community response to the projects--especially the poster display-- indicate that the project is both a highly effective learning experience and a health-promoting activity in its own right.     

Patients teach students: partners in arthritis education

CONTEXT: A large metropolitan teaching hospital within The Northern Clinical School, University of Sydney. OBJECTIVE: To assess whether students taught by trained patients (Patient Partners) acquire the same levels of competence in musculoskeletal examination skills for arthritis as students taught by Consultant Rheumatologists. SUBJECTS: Year four medical students in a six-year Undergraduate Medical Programme. METHOD: Students randomized to eight tutorial groups were taught musculoskeletal examination skills in a 75-90 minute tutorial. Four groups were taught by Consultants with an untrained patient present and four groups were taught by Patient Partners. RESULTS: Students' mean self-ratings of skill before and after their tutorial were summed. For both groups, self-ratings before the tutorial were similar. After the tutorial both groups showed substantial gains in levels of skill. Patient Partners' ratings of students' taught by either Consultants or Partners were comparable. CONCLUSIONS: Patient Partners are at least equal to Consultant Rheumatologists in the teaching of musculoskeletal examination techniques for arthritis.     

早期气道状况评估对急诊科危重症患者救治的影响

目的探讨早期气道评估对急诊科危重症患者救治的影响。方法将166例行气管插管的危重症患者按是否行早期气道评估分为早期评估组（86例）和对照组（80例）,对照组患者因病情变化需要建立人工气道时,由值班医生进行首次气管插管,并在插管前采用喉镜观察分级评估气道;早期评估组患者入急诊科时即由值班医生采用改良的Mallampati分级及甲颏距离测量进行早期气道评估。记录两组首次气管插管成功例数、气管插管时间、预估为困难气道的例数、预估为困难气道首次插管成功的例数、气管插管失败需行紧急气管造口的例数、生命体征相对稳定达转送的间隔时间、急诊科内死亡例数。结果两组气管插管时间、预估为困难气道率、气管插管失败需要行紧急气管造口置管率比较差异均无统计学意义（p〉0．05）;早期评估组首次气管插管成功率和预估为困难气道首次插管成功率均明显高于对照组[69．4％（59／85）比40．0％（32,80）、80．0％（28／35）比32．3％（10／31）],生命体征相对稳定达转送的间隔时间明显短于对照组[（89．5±23．2）min比（110．4±48．2）min],急诊科内病死率明显低于对照组[8．2％（7／85）比18．8％（15,80）],差异均有统计学意义（P〈0．05）。结论在急诊科早期对患者进行气道评估并做好相应的准备工作有利于提高急诊困难气道患者的首次气管插管成功率,有助于患者病情稳定,及早达到安全转送的标准。     

Benefits of computer screen‐based simulation in learning cardiac arrest procedures

Medical Education 2010: 44 : 716–722 Objectives What is the best way to train medical students early so that they acquire basic skills in cardiopulmonary resuscitation as effectively as possible? Studies have shown the benefits of high‐fidelity patient simulators, but have also demonstrated their limits. New computer screen‐based multimedia simulators have fewer constraints than high‐fidelity patient simulators. In this area, as yet, there has been no research on the effectiveness of transfer of learning from a computer screen‐based simulator to more realistic situations such as those encountered with high‐fidelity patient simulators. Methods We tested the benefits of learning cardiac arrest procedures using a multimedia computer screen‐based simulator in 28 Year 2 medical students. Just before the end of the traditional resuscitation course, we compared two groups. An experiment group (EG) was first asked to learn to perform the appropriate procedures in a cardiac arrest scenario (CA1) in the computer screen‐based learning environment and was then tested on a high‐fidelity patient simulator in another cardiac arrest simulation (CA2). While the EG was learning to perform CA1 procedures in the computer screen‐based learning environment, a control group (CG) actively continued to learn cardiac arrest procedures using practical exercises in a traditional class environment. Both groups were given the same amount of practice, exercises and trials. The CG was then also tested on the high‐fidelity patient simulator for CA2, after which it was asked to perform CA1 using the computer screen‐based simulator. Performances with both simulators were scored on a precise 23‐point scale. Results On the test on a high‐fidelity patient simulator, the EG trained with a multimedia computer screen‐based simulator performed significantly better than the CG trained with traditional exercises and practice (16.21 versus 11.13 of 23 possible points, respectively; p < 0.001). Conclusions Computer screen‐based simulation appears to be effective in preparing learners to use high‐fidelity patient simulators, which present simulations that are closer to real‐life situations.     

Airtraq喉镜用于困难气道的临床观察

目的：观察airtraq喉镜用于困难气管内插管的临床效果.方法：选择ASAⅠ~Ⅱ级,cormark-lehane评分Ⅲ~Ⅳ,年龄20~60岁,拟行择期腹部手术的患者50例,随机分为airtraq喉镜组（A组,25例）和macinton喉镜组（M组,25例）,常规静脉全麻诱导后分别使用airtraq喉镜和macintosh喉镜进行声门暴露和插管.观察记录两组患者气管插管次数和时间,各时刻平均动脉压（MAP）,心率（HR）以及相关不良反应.结果：两组比较,A组一次成功插管例数高于M组（P〈0.05）：A组建立有效气道的时间比M组短（P〈0.05）,M组插管后3 min的MAP和HR较A组显著升高（P〈0.05）：A组口腔黏膜出血及咽喉疼痛的患者少于M组（P〈0.05）.结论：airtraq喉镜能有效解决困难气道插管,具有快速,声门暴露好,插管损伤小的优点.