Do worked examples foster medical students’ diagnostic knowledge of hyperthyroidism?

Objectives In an initial experimental study in the domain of learning about hypertension, a case‐based, worked example approach was found to be most effective when erroneous examples and elaborated feedback were provided. However, combining erroneous examples with knowledge of correct result (KCR) feedback impaired learning. This study was designed to establish whether these findings could be replicated in the domain of learning about hyperthyroidism. Methods A total of 124 medical students were randomly assigned to the four conditions of a 2 × 2 design (with errors versus without errors; elaborated feedback versus KCR feedback). Diagnostic knowledge was operationalised by a multiple‐choice test, key feature problems and problem‐solving tasks. Acceptance and subjective learning outcomes were assessed on three rating scales. Results The combination of erroneous examples and elaborated feedback was the most effective learning condition, whereas erroneous examples with KCR feedback impaired knowledge acquisition. These effects were independent of differences in prior knowledge and time on task and replicated key findings of the study on hypertension diagnostics. Additionally, results showed that students in conditions with elaborated feedback assessed their learning outcomes as significantly higher than students receiving KCR feedback only. Conclusions By providing erroneous examples in combination with elaborated feedback in a computer‐based learning environment, diagnostic knowledge was fostered. The approach of ‘learning from worked examples’ was successfully adapted to a complex domain and was found to support the acquisition of complex competencies.     

Preservice early childhood students’ perceptions of written feedback on their essays

Lecturer feedback on students’ essays is important to the quality of the experience students have at university (). The aim of the present study was to investigate whether early childhood students at one university actually read lecturer feedback on their essays and, if they did, what they found helpful and not helpful to their learning. Feedback was defined as ‘giving students information on how well or how poorly they are doing in their academic work’ (, p. 109). Using the Vygotskian concept of learning as a socially shared activity, qualitative data were collected from second‐year students from a four‐year early childhood degree programme via an anonymous survey and four focus groups. Major findings were that, in contrast with studies of students in other programmes, early childhood students read lecturer feedback on their essays and used feedback that was detailed and explanatory as a learning tool. Types of feedback students found to be most and least useful were identified.     

Maturational differences in undergraduate medical students' perceptions about feedback

Medical Education 2012: 46: 711–721 Context Although medical students receive varied feedback throughout their training programmes, research demonstrates that they frequently perceive it as insufficient. However, supervisors tend to perceive that it is adequate. Students’ responses to, and use of, feedback are not clearly understood. The purposes of this study were to investigate how medical students recognise, respond to and utilise feedback, and to determine whether there are maturational differences in understandings of the role of feedback across academic years in medical school. Methods This was a mixed‐methods study collecting qualitative (focus group and open‐ended questionnaire items) and quantitative (questionnaire) data across the 5 years of an undergraduate programme. Results A total of 68 students participated in 10 focus groups. The questionnaire response rate was 46% (564/1233). Data analysis investigated the students’ perceptions of feedback and explored patterns of responses across the continuum of undergraduate medical school stages. Maturational differences among the year cohorts within the programme emerged in three general areas: (i) student perceptions of the purpose of feedback; (ii) student recognition of feedback, and (iii) student perceptions regarding the credibility of feedback providers. Conclusions Junior students generally perceived the receiving of feedback as a passive activity and preferred positive feedback that confirmed their progress and provided reassurance. More senior students viewed feedback as informing their specific learning needs and personal development. They valued immediate informal verbal feedback and feedback from peers and others, as well as that from senior teachers. Exploring students’ progressive degrees of engagement with feedback and its relationship with self‐esteem are subjects for further study.     

At-risk medical students: implications of students' voice for the theory and practice of remediation

Medical Education 2010: 44 : 1038–1047 Objectives A mandatory remedial programme for students who repeat their first semester at medical school has resulted in large gains in academic performance and greatly reduced attrition. Here, we explore the students’ views of this in order to clarify understanding of optimal remediation practice. Methods Using a mixed‐methods approach, quantitative and qualitative data were gathered from student surveys (n = 333) and three in‐depth focus groups. Results were analysed for emergent themes. Results Remedial programmes for at‐risk medical students should be mandatory, but should respect students’ identity as repeaters. Attitude and motivation are key, and working in stable groups provides essential emotional and cognitive support. The learning environment needs to foster changes in students’ ways of thinking and their development as flexible, reflective learners. These endeavours require support from honest teachers with rigorous expectations and good facilitation skills. Conclusions Successful remediation needs to challenge students’ conceptions of learning, works best in groups with skilled facilitators, and must take into account a blend of cognitive and affective factors and the complex interplay between learner and environment. Given a carefully designed programme, at‐risk medical students can learn to make effective and lasting changes to their approach to study, and their views of learning can come to converge with influential ideas in the education literature.     

An exploration of perceptions of tutor evaluation in problem‐based learning tutorials

Medical Education 2010: 44 : 892–899 Context Within problem‐based learning (PBL) tutorials, the relationship between student and tutor is predicated on the tutor adopting the role of mentor and metacognitive coach. This rapport differs considerably from the traditional teacher–student relationship and is likely to impact on the process and outcomes of tutor evaluations. Such evaluations are a ubiquitous means of providing feedback to tutors from students about the quality of their facilitation. Although critiqued in the literature as ‘popularity contests’, tutor evaluations are commonly used in tertiary institutions for purposes of recruitment, re‐employment and promotion. Methods This study seeks to provide insight into students’ and tutors’ perceptions of evaluations of teaching within PBL tutorials. As a unique teaching and learning environment, the PBL tutorial requires sophisticated facilitation skills of tutors and considerable autonomy from students. Qualitative data were gathered from three focus group discussions and one in‐depth interview with first‐ and second‐year medical students and their PBL tutors. Results Thematic analysis identified four major themes, including: defining the ‘ideal’ tutor; making unthinking or deliberately false evaluations; promoting a consumer mentality, and providing support for tutors. An underlying suspicion of the purpose of the evaluation process was apparent among tutors and students. Conclusions Findings suggest that, within the PBL tutorial environment at least, regularly evaluating tutors creates mistrust and confusion among the medical school, the tutor and the student on several levels. Suggestions for further research are proposed.     

The development and evaluation of Student Training, Education and Practice for Dietetics CD-ROM: a computer-assisted instruction programme for dietetic students

The Student Training, Education and Practice for Dietetics (STEP‐DIET) CD‐ROM was developed at the University of Surrey to prepare dietetic students for the practical dietetic training component of their Nutrition/Dietetics degree. This study aimed to evaluate student response to the programme and its effectiveness as a teaching tool, based on the evaluation framework of D.L. Kirkpatrick (Evaluating a Course, 2nd edn. London, Kogan Page). Quantitative and qualitative methodologies were employed, with 41 dietetic students, separated by year group, completing questionnaires and taking part in six focus groups, at the University of Surrey. Student attitudes towards the instruction method and the STEP‐DIET programme itself were investigated, in conjunction with their perceived learning achievements. Students rated the programme highly in terms of design and content, however, there was a reluctance to accept computer‐assisted instruction (CAI) as a sole teaching method. A number of learning achievements relevant to dietetic practice were reported including a perceived increase in ability to conduct a dietetic interview and an increased understanding of the management of Type 2 diabetes. In general students reacted positively to the STEP‐DIET programme and it was perceived by students to be effective in preparing them for the practical component of their dietetic training.     

Examining the presence of computer-assisted instruction in physical therapy education

The purpose of this study was to compare computer-assisted instruction (CAI) use in physical therapist (PT) and physical therapist assistant (PTA) education programs. Secondary purposes included examining faculty attitudes toward CAI, selection criteria, and evaluation criteria. Questionnaires were mailed to 389 PT and PTA programs. The total return rate was 52% (N = 201). Frequencies, percentages, and modes of responses were calculated for each questionnaire item. Eight percent of PT and 35% of PTA programs indicated that all faculty are using CAI, whereas 3% of PT and 6% of PTA reported that no faculty are using CAI. PT program respondents indicated using nine different types of CAI, whereas PTA programs indicated using eight different types. Fifty-seven percent of PT and 33% of PTA programs provide formal computer instruction. Forty-six percent of PT and 47% of PTA programs have a computer prerequisite. Nine percent of PT and 0% of PTA programs have mandatory computer ownership or lease policies. Positive aspects reported included improved knowledge of technology and independence with information gathering. Negative aspects reported included cost and time. Respondents were unsure whether different students benefit more from CAI (high or low aptitude, learning style) Results indicated that criteria for selecting CAI material are based on cost, ease of use, and compatibility with current systems rather than instructional design, and evaluation procedures included student outcomes and course evaluations. Contextual differences between PT and PTA probably account for differences in types and uses of CAI for PT and PTA programs. Instructor feedback is important when using CAI to teach psychomotor skills. More research is needed to determine if one type of student benefits more than others. Programs should consider the instructional design of CAI materials, in addition to practical aspects such as cost, and ease of use. We need to be aware of the instructional goals, content, and learners when selecting, designing, and using CAI.     

The role of peer-assisted learning in building evaluative judgement: opportunities in clinical medical education

This study explored the contribution of peer-assisted learning (PAL) in the development of evaluative judgement capacity; the ability to understand work quality and apply those standards to appraising performance. The study employed a mixed methods approach, collecting self-reported survey data, observations of, and reflective interviews with, the medical students observed. Participants were in their first year of clinical placements. Data were thematically analysed. Students indicated that PAL contributed to both the comprehension of notions of quality, and the practice of making comparisons between a given performance and the standards. Emergent themes included peer story-telling, direct observation of performance, and peer-based feedback, all of which helped students to define ‘work quality’. By participating in PAL, students were required to make comparisons, therefore using the standards of practice and gaining a deeper understanding of them. The data revealed tensions in that peers were seen as less threatening than supervisors with the advantage of increasing learners’ appetites for thoughtful ‘intellectual risk taking’. Despite this reported advantage of peer engagement, learners still expressed a preference for feedback from senior teachers as more trusted sources of clinical knowledge. While this study suggests that PAL already contributes to the development of evaluative judgement, further steps could be taken to formalise PAL in clinical placements to improve learners’ capacity to make accurate judgements on the performance of self and others. Further experimental studies are necessary to confirm the best methods of using PAL to develop evaluative judgement. This may include both students and educators as instigators of PAL in the workplace.     

Stakes in the eye of the beholder: an international study of learners’ perceptions within programmatic assessment

Objectives

Within programmatic assessment, the ambition is to simultaneously optimise the feedback and the decision‐making function of assessment. In this approach, individual assessments are intended to be low stakes. In practice, however, learners often perceive assessments designed to be low stakes as high stakes. In this study, we explored how learners perceive assessment stakes within programmatic assessment and which factors influence these perceptions.

Methods

Twenty‐six learners were interviewed from three different countries and five different programmes, ranging from undergraduate to postgraduate medical education. The interviews explored learners’ experience with and perception of assessment stakes. An open and qualitative approach to data gathering and analyses inspired by the constructivist grounded theory approach was used to analyse the data and reveal underlying mechanisms influencing learners’ perceptions.

Results

Learners’ sense of control emerged from the analysis as key for understanding learners’ perception of assessment stakes. Several design factors of the assessment programme provided or hindered learners’ opportunities to exercise control over the assessment experience, mainly the opportunities to influence assessment outcomes, to collect evidence and to improve. Teacher–learner relationships that were characterised by learners’ autonomy and in which learners feel safe were important for learners’ believed ability to exercise control and to use assessment to support their learning.

Conclusions

Knowledge of the factors that influence the perception of assessment stakes can help design effective assessment programmes in which assessment supports learning. Learners’ opportunities for agency, a supportive programme structure and the role of the teacher are particularly powerful mechanisms to stimulate the learning value of programmatic assessment.     

Student perceptions of assessment and feedback in longitudinal integrated clerkships

Objectives This study was conducted to elucidate how the learning environment and the student–preceptor relationship influence student experiences of being assessed and receiving feedback on performance. Thus, we examined how long‐term clinical clerkship placements influence students’ experiences of and views about assessment and feedback. Methods We took a constructivist grounded approach, using authentic assessment and communities of practice as sensitising concepts. We recruited and interviewed 13 students studying in longitudinal integrated clerkships across two medical schools and six settings, using a semi‐structured interview framework. We used an iterative coding process to code the data and arrive at a coding framework and themes. Results Students valued the unstructured assessment and informal feedback that arose from clinical supervision, and the sense of progress derived from their increasing responsibility for patients and acceptance into the health care community. Three themes emerged from the data. Firstly, students characterised their assessment and feedback as integrated, developmental and longitudinal. They reported authenticity in the monitoring and feedback that arose from the day‐to‐day delivery of patient care with their preceptors. Secondly, students described supportive and caring relationships and a sense of safety. These enabled them to reflect on their strengths and weaknesses and to interpret critical feedback as supportive. Students developed similar relationships across the health care team. Thirdly, the long‐term placement provided for multiple indicators of progress for students. Patient outcomes were perceived as representing direct feedback about students’ development as doctors. Taking increasing responsibility for patients over time is an indicator to students of their increasing competence and contributes to the developing of a doctor identity. Conclusions Clerkship students studying for extended periods in one environment with one preceptor perceive assessment and feedback as authentic because they are embedded in daily patient care, useful because they are developmental and longitudinal, and constructive because they occur in the context of a supportive learning environment and relationship.     

Learning preferences, computer attitudes, and student evaluation of computerised instruction

OBJECTIVE: To explore the relationship between learning preferences, attitudes towards computers, and student evaluation of a computer-assisted instructional (CAI) program. CONTEXT: A third year required clerkship in surgery at the University of Nebraska Medical Center. METHODS: A mixed-methods design combining attitudinal measures and qualitative interviews was employed to assess student reactions to a CAI program on angiography completed during a required surgical clerkship. Between January 1998 and July 1999, 151 students completed the program. Prior to participating, students completed the Rezler Learning Preference Inventory (LPI) and a computer attitudes survey (CAS). The LPI characterizes learning preferences as being abstract or concrete, individual or interpersonal, and student-structured or teacher-structured. The CAS measures attitudes towards computers and their role in education. After using the CAI program, students evaluated the module by completing an 18 item questionnaire. Based on LPI and CAS scores, 31 students were invited to participate in an in-depth qualitative interview on their experiences and perceptions of the program. RESULTS: There was no relationship between learning preferences, computer attitudes, and evaluation of the CAI program. Students were very positive about the program's content, clarity, organization, and ease of use. They also rated it as efficient and effective. However, many still indicated a preference for lecture and text-based learning. Qualitative interviews suggest students worry computers will supplant student--teacher contact. CONCLUSIONS: Learning preferences and prior attitudes toward computers did not bias student reactions to the CAI program assessed in this study. However, students expressed concerns that CAI would interfere with the traditional student--teacher encounter and relationship.     

Visualising the invisible: a network approach to reveal the informal social side of student learning

World-wide, universities in health sciences have transformed their curriculum to include collaborative learning and facilitate the students’ learning process. Interaction has been acknowledged to be the synergistic element in this learning context. However, students spend the majority of their time outside their classroom and interaction does not stop outside the classroom. Therefore we studied how informal social interaction influences student learning. Moreover, to explore what really matters in the students learning process, a model was tested how the generally known important constructs—prior performance, motivation and social integration—relate to informal social interaction and student learning. 301 undergraduate medical students participated in this cross-sectional quantitative study. Informal social interaction was assessed using self-reported surveys following the network approach. Students’ individual motivation, social integration and prior performance were assessed by the Academic Motivation Scale, the College Adaption Questionnaire and students’ GPA respectively. A factual knowledge test represented student’ learning. All social networks were positively associated with student learning significantly: friendships (β?=?0.11), providing information to other students (β?=?0.16), receiving information from other students (β?=?0.25). Structural equation modelling revealed a model in which social networks increased student learning (r?=?0.43), followed by prior performance (r?=?0.31). In contrast to prior literature, students’ academic motivation and social integration were not associated with students’ learning. Students’ informal social interaction is strongly associated with students’ learning. These findings underline the need to change our focus from the formal context (classroom) to the informal context to optimize student learning and deliver modern medics.     

Teaching pathology via online digital microscopy: positive learning outcomes for rurally based medical students

Introduction: Technology has revolutionised teaching. Teaching pathology via digital microscopy (DM) is needed to overcome increasing student numbers, a shortage of pathology academics in regional medical schools, and difficulties with teaching students on rural clinical placement. Objective: To identify whether an online DM approach, combining digital pathology software, Web‐based slides and classroom management software, delivers effective, practical pathology teaching sessions to medical students located both on campus and on rural placement. Methods: An online survey collected feedback from fourth and fifth year undergraduate James Cook University medical students on the importance of 16 listed benefits and challenges of using online DM to teach pathology, via a structured five‐point Likert survey. Results: Fifty‐three students returned the survey (response rate = 33%). Benefits of online DM to teach pathology rated as ‘very important’ or ‘extremely important’ by over 50% of students included: higher quality images; faster learning; more convenient; better technology; everyone sees the same image; greater accessibility; helpful annotations on slides; cost savings; and more opportunity for self‐paced learning out‐of‐hours and for collaborative learning in class. Challenges of online DM rated as ‘very important’ or ‘extremely important’ by over 50% of students included: Internet availability in more remote locations and potential problems using online technology during class. Conclusions: Nearly all medical students welcomed learning pathology via online digital technology. DM should improve the quantity, quality, cost and accessibility of pathology teaching by regional medical schools, and has significant implications for the growing emphasis in Australia for decentralised medical education and rural clinical placements.     

An evaluation of a community dietetics intervention on the management of malnutrition for healthcare professionals

Background: Healthcare professionals working in the community setting have limited knowledge of the evidence‐based management of malnutrition. The present study aimed to evaluate a community dietetics intervention, which included an education programme for healthcare professionals in conjunction with the introduction of a community dietetics service for patients ‘at risk’ of malnutrition. Changes in nutritional knowledge and the reported management of malnourished patients were investigated and the acceptability of the intervention was explored. Methods: An education programme, incorporating ‘Malnutrition Universal Screening Tool (MUST)’ training, was implemented in eight of 10 eligible primary care practices (14 general practitioners and nine practice nurses attended), in seven private nursing homes (20 staff nurses attended) and two health centres (53 community nurses attended) in conjunction with a community dietetics service for patients at risk of malnutrition. Nutritional knowledge was assessed before, immediately after, and 6 months after the intervention using self‐administered, multiple‐choice questionnaires. Reported changes in practice and the acceptability of the education programme were considered using self‐administered questionnaires 6 months after the intervention. Results: A significant increase in nutritional knowledge 6 months after the intervention was observed (P < 0.001). The management of malnutrition was reported to be improved, with 69% (38/55) of healthcare professionals reporting to weigh patients ‘more frequently’, whereas 80% (43/54) reported giving dietary advice to prevent or treat malnutrition. Eighty‐percent (44/55) of healthcare professionals stated that ‘MUST’ was an acceptable nutrition screening tool. Conclusion: An education programme supported by a community dietetics service for patients ‘at risk’ of malnutrition increased the nutritional knowledge and improved the reported management of malnourished patients in the community by healthcare professionals.     

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.     

Help,I’m losing patient‐centredness! Experiences of medical students and their teachers

Medical Education 2010: 44 : 662–673 Objectives Despite all educational efforts, the literature shows an ongoing decline in patient‐centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient‐centredness in order to gain a better understanding of the factors that determine its development. Methods We conducted 11 focus groups on the subject of learning and teaching about patient‐centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the ‘sensitising concepts’ provided by the Attitude–Social Influence–Self‐Efficacy (ASE) model. Results Although students express positive attitudes towards patient‐centredness and acquire patient‐centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today’s challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient‐centred skills. However, when students lack self‐efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non‐patient‐centred role models and are overwhelmed by powerful experiences, they lose their patient‐centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self‐awareness and self‐care are important qualities of the central phenomenon of the ‘doctor‐as‐person’, which is identified as a missing concept in the ASE model. The student–supervisor relationship is found to be key to learning patient‐centredness and has several functions: it facilitates the direct transmission of patient‐centred skills, knowledge and attitudes; it provides social support of students’ patient‐centred behaviour; it provides support of the ‘student‐as‐person’; it mirrors patient‐centredness by being student‐centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student‐centred education and guidance be offered, self‐awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. Conclusions Supportive student–doctor relationships, student‐centred education and guidance that addresses the needs of the doctor‐as‐person are central to the development of patient‐centredness. Medical education requires patient‐centred, self‐caring and self‐aware role models.