Successful teaching in evidence-based medicine

OBJECTIVES: Several published articles have described the importance of exposing medical trainees to the 'new paradigm' of evidence-based medicine (EBM). Recognizing this, we sought to develop and objectively evaluate a mini-course in EBM for third-year medical students. DESIGN: We developed a mini-course consisting of four sessions in which students learn to derive sequentially focused questions, search MEDLINE, review articles critically and apply information from the literature to specific clinical questions. To evaluate the teaching intervention, we performed a controlled educational study. Students at the intervention site (n=34) attended the EBM mini-course, while students at the control site (n=26) received more 'traditional' didactic teaching on various clinical topics. Intervention and control students were surveyed immediately before and after the mini-course to assess changes in reading and literature searching skills, as well as a tendency to use the literature to answer clinical questions. SETTING: Boston University School of Medicine. SUBJECTS: Third-year medical students. RESULTS: The intervention was associated with significant changes in students' self-assessed skills and attitudes. MEDLINE and critical appraisal skills increased significantly in the intervention group relative to the control group (significance of between group differences: P=0.002 for MEDLINE and P=0.0002 for critical appraisal), as did students' tendency to use MEDLINE and original research articles to solve clinical problems (significance of between group differences: P=0.002 and P=0.0008, respectively). CONCLUSIONS: We conclude that this brief teaching intervention in EBM has had a positive impact on student skills and attitudes at our medical school. We believe that the key elements of this intervention are (1) active student involvement, (2), clinical relevance of exercises and (3) integrated teaching targeting each of the component skills of EBM.     

Clinical skills training: developing objective assessment instruments

The purpose of this study was to develop objective assessment instruments for use in psychomotor skill training and to test the instruments for interobserver reliability. Two checklist style instruments, one for suturing and one for endotracheal intubation, were developed through a process of review of standard texts, consultation with local experts and field testing. Following development they were used by paired examiners in an Objective Structured Clinical Examination (OSCE) setting to test the instruments for interobserver reliability. A total of 88 final year medical students were recruited from the five Ontario medical schools to participate as examinees. The checklists worked well within the practical constraints of a 10 minute OSCE station and demonstrated a high level of interobserver reliability with Kappa scores of 0·65 for the suturing checklist and 0·71 for the intubation checklist. Furthermore, the Kappa scores for individual checklist items served to identify items which demonstrated poor interobserver reliability and thus highlighted them for review.     

Use of a journal club and letter-writing exercise to teach critical appraisal to medical undergraduates

INTRODUCTION: There is growing interest in methods of teaching critical appraisal skills at undergraduate and postgraduate levels. We describe an approach using a journal club and subsequent letter writing to teach critical appraisal and writing skills to medical undergraduates. METHODS: The exercise occurs during a 3-week public health medicine attachment in the third year of the undergraduate curriculum. Students work in small groups to appraise a recently published research paper, present their findings to their peers in a journal club, and draft a letter to the journal editor. Evaluation took place through: informal and formal feedback from students; number of letters written, submitted and published, and a comparison of marks obtained by students submitting a literature review assignment with and without critical appraisal teaching during the public health attachment. RESULTS: Feedback from students was overwhelmingly positive. In the first 3(1/2) years, 26 letters have been published or accepted for publication, and 58 letters published on the Internet. There were no significant differences in overall marks or marks for the critical appraisal component of the literature review assignments between the two student groups. DISCUSSION: We believe our approach is an innovative and enjoyable method for teaching critical appraisal and writing skills to medical students. Lack of difference in marks in the literature review between the student groups may reflect its insensitivity as an outcome measure, contamination by other critical appraisal teaching, or true ineffectiveness.     

Helping general practitioners to keep up with the literature: evaluation of an RCGP initiative

The recent Report of The Medical Information Review Panel suggested that locally-produced abstracting bulletins are likely to be of great value in promoting continuing education; most notably by helping GPs to 'keep up with the literature'. The Report identified Current Medical Abstracts for Practitioners (CMAP) , a publication produced by the S.E. Scotland Faculty of the Royal College of General Practitioners (RCGP), as an example of the kind of bulletin it had in mind. It further suggested that the role and effectiveness of this publication should be investigated.
A survey of the readership of CMAP was therefore carried out. It was found that CMAP is regularly read by only 28% of those to whom it is sent (free of charge). More particularly, CMAP is read predominantly by those GPs who are already conscientious users of medical literature: they use the bulletin as a complement and supplement to their other professional reading. Those GPs who devote little time to journal reading, in general, tend to ignore CMAP. They do not seek to use it as a substitute for more extensive reading of medical journals.
It therefore appears that CMAP does little to overcome the problem of GPs who do not keep up with the literature, and it is unlikely that similar publications will be initiated in other areas. Indeed, publication of CMAP may be ceased, at least in its present form.     

Refuting patients' obligations to clinical training: a critical analysis of the arguments for an obligation of patients to participate in the clinical education of medical students

CONTEXT: The clinical teaching of medical students is essential to the continuation of medicine, but it has a major impact on the patient's health care and autonomy. Some people believe that there is a moral obligation for patients to participate in this training. Such an obligation, real or perceived, may endanger patients' autonomy. OBJECTIVES: The author makes a critical analysis of the main arguments he encounters supporting such an obligation. These arguments are: (1) the furthering of medical education; (2) compensation when uninsured or unable to pay; (3) an equitable return for the care received in a teaching hospital, and (4) fulfilment of a student's need for (and some say right to) clinical training. METHODS: Related literature is reviewed in search of evidence and/or support for such arguments. CONCLUSIONS: The review reveals that these arguments either cannot be verified or do not necessarily place any obligations on the patient. It is argued that, while a medical student may have a right to clinical education, the obligation to fulfil this right rests with the medical university and not on the patients of its teaching hospitals. SOLUTIONS: Several proposals are made about how to satisfy this need without infringing on the patient's right to refuse participation, explaining the patient's rights and role in clinical teaching, and the use of standardized patients where necessary.     

What do medical students read and why? A survey of medical students in Newcastle‐upon‐Tyne,England

OBJECTIVES: There is increasing interest in the role of medical humanities within the undergraduate curriculum, but we know little about medical students' views on this or about their reading habits. Our study explored the reading habits of medical students, and their attitudes towards literature and the introduction of humanities into the curriculum. DESIGN: Self-completion questionnaire survey. SETTING: Newcastle University and Medical School. SUBJECTS: All first-, second- and third-year undergraduate medical students (384), biology students (151) and a random sample of law students (137) were sent a self-completion questionnaire to assess reading levels, attitudes towards literature and the medical humanities (medical students) and the perceived benefits of reading. RESULTS: Medical students read widely beyond their course and articulate a range of benefits from this, including: increasing awareness of life outside their experience; introspection or inspiration; emotional responses; and stimulation of an interest in reading or literature. Of the medical students, 40% (103/258) read one or more fiction books per month, but 75% (193) read fewer non-curricular books since starting university, largely because of time pressures, work, study or academic pressures and restricted access to books. A total of 77% (194) thought that medical humanities should definitely or possibly be offered in the curriculum, but of these 73% (141) thought it should be optional and 89% (172) that it should not be examined. CONCLUSIONS: Medical students read literature for a variety of very positive and valued reasons, but have found leisure reading harder to maintain since starting university. They support inclusion of the humanities in medical education, but have mixed views on how this should be done.     

Stress, coping and health: enhancing well-being during medical school

Summary. Medical education can be a health hazard for many students, and far-reaching reforms are needed to improve it. This article reviews the literature on stress, coping and health during undergraduate medical education. The conclusions drawn from this review are used as a basis for advancing recommendations to improve medical education. It is essential to incorporate the principles of health promotion and disease prevention throughout medical education in order to minimize and prevent later burn-out and impairment. Healthy medical students are likely to become healthy doctors who can then model and promote healthy lifestyles with their patients. This preventive approach to health care can lead to an improvement in our health care delivery system.     

Teaching anatomy without cadavers

BACKGROUND: Anatomy learning is generally seen as essential to medicine, and exposure to cadavers is generally seen as essential to anatomy learning around the world. Few voices dissenting from these propositions can be identified. AIMS: This paper aims to consider arguments relating to the use of cadavers in anatomy teaching, and to describe the rationale behind the decision of a new UK medical school not to use cadaveric material. DISCUSSION: First, the background to use of cadavers in anatomy learning is explored, and some general educational principles are explored. Next, arguments for the use of human cadaveric material are summarised. Then, possible arguments against use of cadavers, including educational principles as well as costs, hazards and practicality, are considered. These are much less well explored in the existing literature. Next, the rationale behind the decision of a new UK medical school not to use cadaveric material is indicated, and the programme of anatomy teaching to be employed in the absence of the use of human remains is described. Curriculum design and development, and evaluation procedures, are briefly described. Issues surrounding pathology training by autopsy, and postgraduate training in surgical anatomy, are not addressed in this paper. FUTURE DIRECTIONS: Evidence relating to the effect on medical learning by students not exposed to cadavers is scant, and plainly opportunities will now arise through our programme to gather such evidence. We anticipate that this discussion paper will contribute to an ongoing debate, in which virtually all previous papers on this topic have concluded that use of cadavers is essential to medical learning.     

Can student tutors act as examiners in an objective structured clinical examination?

Context  The dissemination of objective structured clinical examinations (OSCEs) is hampered by requirements for high levels of staffing and a significantly higher workload compared with multiple-choice examinations. Senior medical students may be able to support faculty staff to assess their peers. The aim of this study is to assess the reliability of student tutors as OSCE examiners and their acceptance by their peers.
Methods  Using a checklist and a global rating, teaching doctors (TDs) and student tutors (STs) simultaneously assessed students in basic clinical skills at 4 OSCE stations. The inter-rater agreement between TDs and STs was calculated by kappa values and paired t -tests. Students then completed a questionnaire to assess their acceptance of student peer examiners.
Results  All 214 Year 3 students at the University of Göttingen Medical School were evaluated in spring 2005. Student tutors gave slightly better average grades than TDs (differences of 0.02–0.20 on a 5-point Likert scale). Inter-rater agreement at the stations ranged from 0.41 to 0·64 for checklist assessment and global ratings; overall inter-rater agreement on the final grade was 0.66. Most students felt that assessment by STs would result in the same grades as assessment by TDs (64%) and that it would be similarly objective (69%). Nearly all students (95%) felt confident that they could evaluate their peers themselves in an OSCE.
Conclusions  On the basis of our results, STs can act as examiners in summative OSCEs to assess basic medical skills. The slightly better grades observed are of no practical concern. Students accepted assessment performed by STs.     

Validation of a new measure of clinical problem-solving

A review of the literature on the assessment of medical problem-solving by means of written tests reveals serious short-comings. Most important is the low correlation repeatedly found among cases, which suggests the inability of the measures to assess a general problem-solving ability. The literature further suggests that instruments should focus on the brief period of time after the first encounter of a clinical problem and warns against the effects of cueing. Based on these considerations a new measure for the assessment of medical problem-solving was developed. This test, called Simulation of Initial Medical Problem-Solving (SIMP), consists of a number of short case histories, followed by an open-ended question. Reliability analysed by means of generalizability theory proved satisfactory and concurrent validity was established by a significant correlation with a global judgement of performance in a simulated patient encounter. The moderate correlation between cases is interpreted as an acceptable correlation among test items and leads to the conclusion that a reliable and valid test of clinical problem-solving should consist of a substantial number of different cases.     

Medical students as standardized patients to assess interviewing skills for pain evaluation

PURPOSE: The use of medical students as standardized patients in a performance assessment of pain evaluation was studied. METHODS: Fifty-two pairs of second-year medical students participated. One student portrayed a patient presenting with cancer pain and was interviewed by the other medical student. The student-patient then rated the interview using a checklist of pain assessment and general interviewing skills. The interviews were audiotaped and also rated independently. RESULTS: Based on student-patient ratings, 36 (69%) students demonstrated 9 or more of the 11 pain-specific checklist items, compared to 34 (65%) students according to the trained rater. Highly specific pain-related items had higher agreement than broader interviewing skill items. There would be differences in the summary assessments of students depending on which rating data were used. DISCUSSION: Medical students represent a readily accessible resource as patients for clinical simulations. Students tended to overestimate the performance of fellow students, but acting as a standardized patient had educational value, and can be used to extend simulated patient encounters within the curriculum. Further investigation is needed to improve the reliability of the feedback provided by student-patients.     

Problem-based learning: why curricula are likely to show little effect on knowledge and clinical skills

OBJECTIVES: A recent review of problem-based learning's effect on knowledge and clinical skills updated findings reported in 1993. The author argues that effect sizes (ES) seen with PBL have not lived up to expectations (0.8-1.0) and the theoretical basis for PBL, contextual learning theory, is weak. The purposes of this study were to analyse what constitutes reasonable ES in terms of the impacts on individuals and published reports, and to elaborate upon various theories pertaining to PBL. DESIGN: Normal theory is used to demonstrate what various ESs would mean for individual change and a large meta-analysis of over 10 000 studies is referred to in identifying typical ESs. Additional theories bearing upon PBL are presented. RESULTS: Effect sizes of 0.8-1.0 would require some students to move from the bottom quartile to the top half of the class or more. The average ES reported in the literature was 0.50 and many commonly used and accepted medical procedures and therapies are based upon studies with ESs below 0.50. CONCLUSIONS: Effect sizes of 0.8-1.0 are an unreasonable expectation from PBL because, firstly, the degree of changes that would be required of individuals would be excessive, secondly, leading up to medical school, students are groomed and selected for success in a traditional curriculum, expecting them to do better in a PBL curriculum than a traditional curriculum is an unreasonable expectation, and, thirdly, the average study reported in the literature and many commonly used and accepted medical procedures and therapies are based upon studies having lesser ESs. Information-processing theory, Cooperative learning, Self-determination theory and Control theory are suggested as providing better theoretical support for PBL than Contextual learning theory. Even if knowledge acquisition and clinical skills are not improved by PBL, the enhanced work environment for students and faculty that has been consistently found with PBL is a worthwhile goal.     

Effective supervision in clinical practice settings: a literature review

CONTEXT: Clinical supervision has a vital role in postgraduate and, to some extent, undergraduate medical education. However it is probably the least investigated, discussed and developed aspect of clinical education. This large-scale, interdisciplinary review of literature addressing supervision is the first from a medical education perspective. PURPOSE: To review the literature on effective supervision in practice settings in order to identify what is known about effective supervision. CONTENT: The empirical basis of the literature is discussed and the literature reviewed to identify understandings and definitions of supervision and its purpose; theoretical models of supervision; availability, structure and content of supervision; effective supervision; skills and qualities of effective supervisors; and supervisor training and its effectiveness. CONCLUSIONS: The evidence only partially answers our original questions and suggests others. The supervision relationship is probably the single most important factor for the effectiveness of supervision, more important than the supervisory methods used. Feedback is essential and must be clear. It is important that the trainee has some control over and input into the supervisory process. Finding sufficient time for supervision can be a problem. Trainee behaviours and attitudes towards supervision require more investigation; some behaviours are detrimental both to patient care and learning. Current supervisory practice in medicine has very little empirical or theoretical basis. This review demonstrates the need for more structured and methodologically sound programmes of research into supervision in practice settings so that detailed models of effective supervision can be developed and thereby inform practice.     

Teaching the consultant teachers: identifying the core content

OBJECTIVES: To determine the key themes for teaching hospital consultants how to teach. DESIGN: 1. In-depth interviews with a total of 19 experts, consultants and junior doctors to identify key topics. 2. Literature review from 1969 to obtain the main themes from the medical educational literature. 3. Analysis of the main themes in 11 'Teaching the teachers' courses. 4. Triangulation of interview data, literature themes and teaching courses content to generate 15 criteria for a questionnaire. 5. Questionnaire study to 593 senior and junior hospital doctors. SETTING: Hospitals in the West Midlands Region in England. SUBJECTS: Consultants and junior hospital doctors. RESULTS: Overall, 441 doctors replied (74% response rate). The top five themes were giving feedback constructively, keeping up to date as a teacher, building a good educational climate, assessing the trainee and assessing the trainee's learning needs. Results showed no statistically significant differences in the order of themes for all groups analysed, including seniority, gender, specialty, origin by medical school and consultants of different ages. CONCLUSIONS: Consultants need teaching in these topics. There are implications for funding and providing these courses for postgraduate deans, Royal Colleges and universities. Further research is needed to evaluate whether such an initiative does produce better teaching and learning, and a better educational climate in hospitals.     

The work of the student doctor: a pilot project

The primary task of the student doctor in the third year of medical school is to inquire into problems of illness, in co-operation with patients, house officers and other staff. This is a new kind of work for most medical students, who have spent the previous two years reading textbooks and listening to lectures. How do students get out of these passive forms of learning into active inquiry? How do they learn to work co-operatively with other people in the technical difficulty and emotional upheaval of illness? We know that most medical students somehow manage to become practicing physicians, but we have known very little about this critical transition. We would expect that this phase of training, like any major transition in the life cycle, leads to great strain and the formation of new patterns of thinking and behaviour that will last through a lifetime of clinical practice. These considerations lead directly to practical matters of medical education and research. How can we best study this critical period? How can we offer the best education to student doctors forming working relationships with patients? This paper describes a working model of training and research to meet these concerns, adapted from the work of Michael Balint and colleagues in the ‘G.P. (General Practitioner) Seminars’( Balint, 1954, 1957 ; Bourne, 1975 ).     

Consulting skills training and medical students' interviewing efficiency

In more traditional medical education, medical students took a patient's medical history by asking a series of sequenced, routine questions, covering presenting medical problem(s); medical history; social and personal history; systems review; and physical examination. Following this process, the student then attempted to derive the patient's medical problems. This inductive problem-solving paradigm may not assist students to prepare for their future interviewing needs, given doctors use a hypothetico-deductive, problem-solving approach when interviewing patients and numerous researchers have developed specialized communication skills training programmes designed to enhance students' interviewing skills. Students given specific consulting skills training have tended to show significantly greater interpersonal effectiveness and improved interview behaviours compared with students who experience traditional patient clerking training. These improvements in interviewing tend to persist over the period of students' medical training. The aim of the present study was to determine whether specialized communication skills training helped students elicit greater quantity and quality of information from patients and if so, whether such information assisted students in improving their diagnostic skills. Videotaped history-taking interviews conducted by students trained in communication skills and untrained (control) students were rated for their interview efficiency. A comparison of ratings given by experimentally naive, independent observers revealed that trained students were more efficient, but took no longer than their control group counterparts to elicit fuller, more relevant information. However, the student groups did not differ in the accuracy or scope of their medical diagnoses. It is argued that students' lack of medical knowledge in this early phase of their clinical training militated against their being able to use their interviewing competence to derive more potentially accurate medical diagnoses.     

Academic training schemes reviewed: implications for the future development of our researchers and educators

CONTEXT: There is an international crisis in academic medicine: numbers of academics are low; there is a split between teaching and research, and career progression is poorly defined. In the UK, academic career pathways have recently been reformed, but there is little readily accessible information on what a high-quality academic training scheme might comprise. METHODS: I conducted a wide review of medical and bio-psychosocial databases, coupled with a search of the grey literature. RESULTS: The review suggests both widespread support for training in research and dissatisfaction with training schemes. Insufficient training time is a major issue. High-quality supervision is crucial, with clear goals and expectations for research fellows. Structured training seems to be helpful, as is financial, administrative and statistical support. However, the vast majority of studies give a broad overview or opinion, or report the superficial results of questionnaire surveys. The focus is on research training; teaching is ignored. CONCLUSIONS: Although there appears to be broad agreement on a number of issues, the literature lacks sufficient depth, and little is known about factors that contribute to effective academic training schemes. Schemes must be studied in depth to determine what makes them successful, in order to ensure the future of teaching and research.