A controlled study of the short- and long-term effects of a Train the Trainers course

Objectives  This study aimed to establish the longterm effects of a 3-day 'Training for Trainers' course (TTC) on doctors' knowledge, teaching behaviour and clinical learning climate.
Methods  The study was designed as an intervention study with pre-, post- and long-term measurements. The intervention group (I-group) included 118 doctors from the departments of internal medicine and orthopaedic surgery at one university hospital. The control group (C-group) consisted of 125 doctors from the corresponding departments at another university hospital. Gains in knowledge about teaching skills were assessed by a written test. Teaching behaviour and learning climate were evaluated by questionnaires.
Results  In the I-group, 98.4% of doctors, both specialists and trainees, participated in a TTC. Response rates on the written test varied from 90% at baseline to 70% at 6 months after the intervention. Knowledge about teaching skills increased in the I-group by 25% after the TTC and was sustained at 6 months. Questionnaire response rates varied from 98.4% at baseline to 84.8% at 6 months. Post-course, the teaching behaviour of the I-group significantly changed and its learning climate improved compared with the C-group. Scores for use of feedback and supervision in the I-group increased from 4–5 to 6–7 (maximum score = 9). This was significantly higher than in the C-group.
Conclusions  A 3-day residential TTC has a significant impact in terms of gains of knowledge concerning teaching skills, teaching behaviour and learning climate after 6 months. The positive effects demonstrated in this study were rooted in both the specialists and trainees who attended the course.     

Training psychiatrists and family doctors in evaluating interpersonal skills

Ten psychiatrists and 15 family doctors were asked to score videotapes of patient-doctor encounters before and after each of two training periods. One period focused on the theory of assessment of doctors' interpersonal skills, while the other was purely practical. Results indicate that after one training session in either theory or practice, both groups of doctors achieved a significantly higher interrater reliability. The second session, which crossed over theory and practice of assessment, did not increase the improvement in interrater agreement achieved by the first training period. Although both groups of doctors showed a significant increase in interrater agreement, psychiatrists exhibited greater reliability scores than family doctors before the experiment as well as after the second training session. These results were discussed in terms of their implicatioins for future research on the doctor-patient relationship.     

Transition to clinical training: influence of pre-clinical knowledge and skills, and consequences for clinical performance

Context  Many students experience a tough transition from pre-clinical to clinical training and previous studies suggest that this may constrict students' progress. However, clear empirical evidence of this is lacking. The aim of this study was to determine: whether the perceived difficulty of transition influences student performance during the first 2 weeks of clerkships; whether it influences students' overall performance in their first clerkship, and the degree to which the difficulty of transition is influenced by students' pre-clinical knowledge and skills levels.
Methods  Clerks ( n  = 83) from a university hospital and eight affiliated hospitals completed a questionnaire measuring the perceived difficulty of the transition period. Data collected included student scores on pre-clinical knowledge and skills, their performance during the second week of the first clerkship, and their overall performance in the first clerkship. Univariate and multivariate multiple regression analyses were used to analyse the data.
Results  The perceived difficulty of transition was neither predictive of student performance during the transition period (adjusted R ² = 11.8%, P  = NS), nor of their overall clerkship performance (adjusted R ² = 8.6%, P  = NS). Students' pre-clinical knowledge and skills played a minor role in the perceived difficulty of the transition period.
Conclusions  The negative effect of the transition period on student progress suggested in the literature was not found in this study. A possible explanation for the limited influence of students' knowledge and skills on performance during the transition period is that the workload in this period causes a cognitive overload, interfering with students' abilities to apply their pre-clinical knowledge and skills.     

Teaching motivational interviewing: using role play is as effective as using simulated patients

Context  Although several studies of motivational interviewing (MI) as an intervention have been conducted, there has been little research into how best to teach MI. Practice and rehearsal is often beneficial in helping practitioners to acquire communication skills, but there have been few studies into what types of practice and rehearsal are most effective.
Methods  Health care professionals (who attended a 2-day workshop in MI) were randomly assigned to conduct skills practice sessions with either a simulated patient (SP) or a fellow trainee. Their competence was assessed before and after training using the Behaviour Change Counselling Index, a validated rating scale. Participants also scored each practice session in terms of their affect and its perceived applicability to everyday clinical work.
Results  There was no significant difference in skill levels between groups following training and no significant difference between groups in their scoring of the affect and applicability of each practice session. There was little indication of an association between how participants felt about their practice sessions and their skill levels.
Conclusions  Trainees reached the same level of competence in MI following a 2-day workshop, regardless of whether they practised with an SP or a fellow trainee during training.     

A skin cancer training programme: evaluation of a postgraduate training for family doctors

This study aimed to evaluate the effectiveness of a postgraduate skin cancer training programme in improving family doctors' levels of knowledge and clinical practice. Forty-one of 59 family doctors (69% consent) who enrolled in the training programme agreed to participate in its evaluation. Approximately half of the doctors were allocated to the 'intervention' group, and the others were in the 'waiting-list' control group. Pre- and post-test data were collected to assess changes in doctors' knowledge, perceived confidence and clinical practice. The training programme involved three sessions, including an information/education session, a practical session at the local Melanoma Unit, and a practical surgical procedures session. There were significant improvements in the proportion of (i) accurate diagnoses, which were made when lesions were presented on colour slides with an accompanying case history; (ii) lesions presented on colour slides in which the correct management of the lesion was identified; and (iii) doctors who felt very or extremely confident in their ability to advise patients on screening frequency, to advise patients on the signs of skin cancer, and to decide whether changes in lesions were malignant. The only improvement observed in the doctors' clinical practice was a significant increase from pre- to post-test in the proportion of pathology request forms on which a diagnosis of the specimen was attempted by doctors in the intervention group compared to those in the control group. The results of this study indicate that whilst significant improvements in knowledge are achievable through postgraduate programmes, clinical practice is much more difficult to change.     

Learning basic surgical skills with mental imagery: using the simulation centre in the mind

Context  Although surgeons and athletes frequently use mental imagery in preparing to perform, mental imagery has not been extensively researched as a learning technique in medical education.
Objective  A mental imagery rehearsal technique was experimentally compared with textbook study to determine the effects of each on the learning of basic surgical skills.
Methods  Sixty-four Year 2 medical students were randomly assigned to 2 treatment groups in which they undertook either mental imagery or textbook study. Both groups received the usual skills course of didactic lectures, demonstrations, physical practice with pigs' feet and a live animal laboratory. One group received additional training in mental imagery and the other group was given textbook study. Performance was assessed at 3 different time-points using a reliable rating scale.
Results  Analysis of variance on student performance in live rabbit surgery revealed a significant interaction favouring the imagery group over the textbook study group.
Conclusions  The mental imagery technique appeared to transfer learning from practice to actual surgery better than textbook study.     

Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients

Objectives  Peer-assisted learning (PAL) has been reported to have educational benefits in cross-year, small-group teaching in other contexts. Accordingly, we explored whether senior medical students are effective tutors for their junior peers in clinical skills education, and how the participants in the learning triad (tutors, learners and simulated patients [SPs]) perceive the learning environment created in PAL.
Methods  Year 2 students were randomly allocated to one of two groups for skills training. Group 1 ( n  = 64) were tutored by volunteer Year 6 students, and Group 2 ( n  = 67) by paid doctors. The results of both groups in a clinical skills examination were compared using an independent samples t -test. Qualitative data, obtained from Year 2 students ( n  = 125) by written questionnaire and Year 6 students ( n  = 11) and SPs ( n  = 3) by focus group interviews, were analysed for themes.
Results  Students receiving PAL did at least as well in the clinical skills examination as students with qualified tutors (difference in mean total score: 0.7 marks out of 112; 95% confidence interval − 3.8 to 2.4). The PAL environment was perceived as 'comfortable' and fostered the development of confidence in all participants. Peer tutors created a more active learning environment than doctor tutors for both learners and SPs and reported personal benefits from teaching.
Conclusions  With appropriate support, volunteer Year 6 student tutors are as effective as graduate doctors for small-group structured tutorials in clinical skills. Educational relationships were forged between all participants in the learning triad.     

Portfolio learning for foundation doctors: early feedback on its use in the clinical workplace

CONTEXT: A learning portfolio was developed to support the development of trainee doctors piloting Foundation Programme prototypes across the Northern Deanery in 2004 and 2005. Trainee doctors and their educational supervisors were surveyed about their experiences of using the portfolio in the clinical workplace. METHODS: The evaluation consisted of semi-structured interviews with trainee doctors and supervisors, followed by postal questionnaire surveys in 2004 and 2005. Quantitative and qualitative data were triangulated to identify core findings. RESULTS: Questionnaires were returned from 182/305 (60%) trainee doctors and 104 out of 179 (58%) educational supervisors. The portfolio was felt to be a 'good idea' by 55% supervisors and 48% trainees. Trainees' perceptions of the educational value of the portfolio remained consistently low over 2 surveys and they described a sense of 'burden', whereby they identified problems in workload and usability and in gaining feedback on performance. However, positive trainee attitudes towards the portfolio were significantly correlated with greater perceived educational benefits (r = 0.855, P < 0.001). DISCUSSION: Learning portfolios are now an integral part of Foundation Programme training but this evaluation suggests that many trainee doctors and educational supervisors are yet to be convinced of their educational value. Gaining multi-source feedback, a substantial component of trainee doctors' portfolios, impacts on the wider clinical team and presents a significant challenge to trainees. Educational supervisors continued to rely on feedback from clinical colleagues, rather than portfolio evidence, to monitor trainee doctors' development. Such factors may serve to disengage trainees with the portfolio process by overshadowing any perceived educational gains.     

Learning the skills of flexible sigmoidoscopy – the wider perspective

Background  Nurse-led gastrointestinal endoscopy is a priority clinical area in the UK. Endoscopic procedures are challenging to learn, requiring a combination of technical competence (manipulating a flexible endoscope and interpreting the findings) and interpersonal skills (engaging effectively with a conscious patient who is frequently apprehensive).
This paper explores the potential of an innovative, scenario-based approach which links a simulated patient with a computer-driven virtual reality (VR) training device for flexible sigmoidoscopy. Within this safe yet realistic quasi-clinical environment, learners carry out the procedure while interacting with the 'patient'. Communication skills are assessed by simulated patients, while quantitative performance data relating to the procedure is generated automatically by the VR simulator.
Methods  This pilot study took place within a nurse practitioner endoscopy course. A mixed methodology combined qualitative and quantitative data (observation and interview studies, communication rating scales and a range of computer-generated output measures from the VR simulator) in a multifaceted evaluation.
Results  Seven nurses took part in the study. Participants found the scenarios to be a convincing and powerful learning experience. All experienced high levels of anxiety. Simulated patients identified strengths in participants' communication skills, together with areas for development. Simulator-based practice led to an improvement in objective performance measures.
Discussion  Scenario-based training provides a powerful learning experience, allowing participants to build their technical expertise and apply it within a holistic clinical context without the risk of causing harm.
We used this pilot study as a springboard for discussions over wider implications of procedure-based skills training, locating it within the literature on expertise and situated learning.     

Student perceptions of a portfolio assessment process

Objectives  The objectives of this study were to identify and analyse students' attitudes to the portfolio assessment process over time.
Methods  A questionnaire containing statements and open questions was used to obtain feedback from students at the University of Dundee Medical School, Scotland. The responses to each statement were compared over 4 years (1999, 2000, 2002 and 2003).
Results  Response rates were 83% in 1999, 70% in 2000, 89% in 2002 and 88% in 2003. A major finding is that students perceived that portfolio building heightened their understanding of the exit learning outcomes and enabled reflection on their work. Student reactions to the portfolio process were initially negative, although they appreciated that senior staff took time to become familiar with their work through reviewing their portfolios. Student attitudes became more positive over the 4 years as the process evolved. Although portfolio assessment was recognised as supporting student learning, portfolio building was perceived to interfere with clinical learning as a result of the excessive amounts of paper evidence required.
Conclusions  Paperwork should be kept within manageable limits. A student induction process that highlights the importance of providing evidence for achieving all learning outcomes, not just theoretical knowledge and skills, may be helpful in allaying student concern over portfolio building and assessment and support preparation for lifelong learning and reflective clinical practice.     

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.     

Teaching doctors how to diagnose paroxysmal events: a comparison of two educational methods

Objectives  Two educational methods, facilitated case discussion and a computerised tutorial, were compared for teaching about childhood epilepsy. We used a comprehensive and clinically relevant assessment method to evaluate the hypothesis that a computerised tutorial more effectively increases knowledge acquisition than a facilitated case discussion.
Methods  Paediatric trainees ( n  = 66) were arbitrarily allocated to facilitated case discussion or computerised tutorial. The analysis of paroxysmal events was taught by the same teacher, using a standardised protocol and principles of active learning. Outcome measures included knowledge acquisition, clinical confidence and usefulness pre- and post-teaching, and at 3 months follow-up.
Results  Computerised tutorial participants scored significantly higher on knowledge acquisition post-teaching. There was gain in clinical confidence in both modalities post-teaching which did not differ between the groups. Confidence and knowledge were not related post-teaching. Both groups found the teaching relevant to clinical practice. However, facilitated case discussion participants rated the session as more enjoyable, and more useful in reinforcing and acquiring knowledge, and felt more motivated for further learning. At 3 months follow-up, participants in both modalities showed significant increases in knowledge acquisition, with no difference between modalities.
Conclusions  The computerised tutorial more effectively imparted knowledge immediately post-teaching. However, facilitated case discussion is the preferred modality in terms of participant enjoyment and perceived usefulness.     

Teaching doctors to take alcohol histories: a limited success story

Doctors often lack the knowledge and skills to identify and assess those who drink to excess and are unsure of what their preventive and educational role should be. As part of a prospective study of early identification and intervention with general hospital patients who drink to excess, we were interested to discover whether brief education about alcohol-related problems and training in the use of a quick and efficient alcohol screening questionnaire would improve doctors' alcohol history-taking and thus their identification of those at risk. The case notes of every fifth admission to orthopaedic and medical wards at the York District Hospital were studied before and after doctor education. Recorded information on both alcohol and tobacco increased over the period reviewed, reflecting perhaps doctors' growing awareness of the health-threatening aspects of these drugs. While there was no major change in doctors' alcohol history-taking, with two thirds of case notes making no mention, or only vague mention, of alcohol, there was a significant post-education increase in the number of patients for whom detailed drinking histories were recorded, but no significant changes in tobacco histories. Small but significant improvements such as these are important in view of the size of the medical problems arising from the use of alcohol.     

The theory of planned behaviour in medical education: a model for integrating professionalism training

Context  Teaching and evaluating professionalism remain important issues in medical education. However, two factors hinder attempts to integrate curricular elements addressing professionalism into medical school training: there is no common definition of medical professionalism used across medical education, and there is no commonly accepted theoretical model upon which to integrate professionalism into the curriculum.
Objectives  This paper proposes a definition of professionalism, examines this definition in the context of some of the previous definitions of professionalism and connects this definition to the attitudinal roots of professionalism. The problems described above bring uncertainty about the best content and methods with which to teach professionalism in medical education. Although various aspects of professionalism have been incorporated into medical school curricula, content, teaching and evaluation remain controversial. We suggest that intervening variables, which may augment or interfere with medical students' implementation of professionalism knowledge, skills and, therefore, attitudes, may go unaddressed.
Discussion  We offer a model based on the theory of planned behaviour (TPB), which describes the relationships of attitudes, social norms and perceived behavioural control with behaviour. It has been used to predict a wide range of behaviours, including doctor professional behaviours. Therefore, we propose an educational model that expands the TPB as an organisational framework that can integrate professionalism training into medical education. We conclude with a discussion about the implications of using this model to transform medical school curricula to develop positive professionalism attitudes, alter the professionalism social norms of the medical school and increase students' perceived control over their behaviours.     

The structure of reflective practice in medicine

BACKGROUND: The capability to reflect consciously upon one's professional practice is generally considered important for the development of expertise and, hence, for education. However, to our knowledge no empirical research has been conducted to date into the nature of reflective practice in medicine. PURPOSE: To study the structure of reflective practice in medicine. METHODS: A questionnaire based on the literature was developed and administered to a group of primary care doctors. The data were subjected to confirmatory factor analysis using structural equations modelling. RESULTS: A 5-factor model of reflective practice emerged. It consisted of the following factors: deliberate induction; deliberate deduction; testing and synthesising; openness for reflection, and meta-reasoning. The model fitted the data sufficiently. CONCLUSION: A multidimensional structure of reflective practice in medicine was brought to light by the study. Its components in terms of reasoning processes, behaviours and attitudes were identified and measured among doctors. Once conceptualised and measured, reflective practice can be studied to gain a better understanding of its relation to expertise development in medicine. In addition, training students to apply reflective practices may become a goal in medical education.     

Short-term outcomes and long-term impact of a programme in medical education for medical students

Objectives  There is growing appreciation of the value of early preparation of future medical educators. Staff development programmes, conferences and workshops pertaining to the training of educators may be crucial to the pursuit of a school's larger educational mission to educate students, doctors and scholars and to provide comprehensive knowledge, research, patient care and service. This study examined the efficacy of a 1-week educational intervention aimed at preparing medical students to become effective doctor educators by building skills early in their careers. The study asked whether participation in a 5-day teacher training programme led to increased knowledge of instructional methods, more favourable attitudes towards teaching, and the integration of structured instructional design methods in a student-developed teaching project.
Methods  A mixed methods research design was employed with quantitative data captured through pre- and post-test inventories, qualitative components captured through written comments, and a 2-year post-intervention survey. Quantitative analyses included pre-/post-intervention repeated measures with calculated effect sizes. Qualitative analysis was conducted using constant comparative methods.
Results  Subjects demonstrated improved content knowledge and more positive attitudes towards motivation, teaching confidence, teacher roles, varied pedagogy, and use of assessment, instructional planning, and evaluation. Subjects were able to incorporate the programme's teaching theory and methods into their teaching projects and assessment of peers' and others' teaching in their own institutions 2 years post-training.
Conclusions  This study demonstrates that a well-designed programme for teacher preparation can be pedagogically effective for training medical students to become better educators and that this learning can be incorporated into long-term practice.     

The development of medical teachers: an enquiry into the learning histories of 10 experienced medical teachers

AIM: The aim of the study was to explore the different ways in which doctors have learned to teach and train. INTRODUCTION: There is no coherent theory of medical teacher development. Doctors are experts in what they teach; most have had little or no training in how they teach. Research has mostly concentrated on the acquisition and improvement of pedagogical skills by attendance at formal, generally short courses. These may have limited impact. METHODS: We carried out semistructured interviews with 10 experienced medical teachers. A review of the literature had suggested areas to explore. Interviews were transcribed and coded and thematic analysis and grounded theory used as the framework for qualitative analysis. RESULTS: Four areas were identified as important in teacher development: acquisition of educational knowledge and skills; modelling and practice of teaching skills; encouragement and motivation of teachers, and constraints on teaching and learning. DISCUSSION: The results suggest a model for teacher development that begins with doctors as learners, learning to learn and watching teachers teach. They then start to teach, acquiring and practising skills, and subsequently move on to reflect on their teaching. They can be encouraged to teach but may also be prevented from teaching. CONCLUSIONS: This inductive study proposes a model for medical teacher development that attempts to explain how doctors learn to teach and train. More research is needed to clarify the findings. There are implications for faculty development.     

Integrating human factors into the medical curriculum

Background  The study of human factors is a scientific discipline that deals with the interactions between human beings and the elements of a system. This is important because shortcomings in these areas, if unchecked, can result in adverse outcomes. Research into human factors in industries where safety is paramount has provided the basis of countermeasures against human error. Adverse outcomes in medicine resulting from human error exact a high cost in both patient suffering and financial outlay.
CRM training  One of the approaches used to minimise the effect of human error is to train people in a set of knowledge, skills and attitudes that underpin the domain-specific competencies for that profession. These are referred to as non-technical skills (NTS). In aviation, such an approach has been shown to be both translatable from the training environment to the workplace and effective in reducing adverse outcomes.
Discussion  Medicine has incorporated this style of training, usually centred around simulator-based courses, but as yet in a piecemeal, episodic fashion which relies on participants volunteering to attend courses. Unlike other industries there is no systematic approach to linking the content of this teaching with the more conventional range of topics. As a consequence it is difficult to assess the impact of human factors training in medicine. This is partly because very little work has been done to date in identifying the key non-technical skills required in medicine, and the overall experience of workplace based assessment is limited. Lessons from other high reliability organisations may help to address the main challenges of developing the content, integrating it into the curriculum, reinforcing the concepts in the workplace through staff development and establishing its role in summative assessment.     

How clinical communication has become a core part of medical education in the UK

Context  This paper sets out to analyse and interpret the complex events of the last 20 years in order to understand how the teaching and learning of clinical communication has emerged as a core part of the modern undergraduate medical curriculum in most medical schools in the UK.
Methods  The paper analyses the effects of key political, sociological, historical and policy influences on clinical communication development.
Results  Political influences include: the effects of neo-liberalism on society and on the professions in general; the challenging of traditional notions of professionalism in medicine; the creation of an internal market within the National Health Service, and the disempowerment of the medical lobby. Sociological influences include: the effects of a 'marketised' society on medicine and subtle shifts in the doctor−patient relationship because of this; the emergence of globalised information through the Internet, and the influence of increased litigation against doctors. Historical influences include: the effects of a change in emphasis for medical education away from an inflated factual curriculum towards a curriculum that recognises the importance of student attitudes and the teaching and learning of clinical communication skills. Policy influences include the important effects of Tomorrow's Doctors and the Dearing Report on the modern medical curriculum.
Conclusions  The paper concludes with a developmental map that charts the complex influences on clinical communication teaching and learning and a brief commentary on the growing body of teachers who deliver and develop the subject today.