Selection of medical students: the Beer-Sheva perspective

Summary: Summary. In many Western medical schools with a low attrition rate the selection of medical students represents the key hurdle for admission to the practice of medicine. The process therefore deserves careful attention. Described herein are impressions and conclusions from almost two decades' experience in selecting medical students at the Ben-Gurion University in Beer-Sheva, Israel.
Emphasis is placed on personal qualities as determined by an interview process of those students who pass a relatively lenient academic threshold. Interviewing is carried out by teams of two, one of whom is a doctor, and each candidate who is accepted is interviewed by four members of the admission committee. Emphasis is placed on clear goals for the interview process, carefully selected and trained interviewers and continual review of the process. In spite of the inherent limitations of a subjective interview process we feel that it offers considerable advantage over other approaches in student selection.     

Teaching bioethics to medical students: the Newcastle experience

Summary. Over the past two decades in the USA, bioethics has become an accepted component of medical education, whereas in Australia, 10 years or even less would encompass the history of most existing programmes. Given the legendary conservatism of medical schools in Australia and the intractability of the medical curriculum, this is still a remarkable achievement. But does the teaching of bioethics change the thinking and/or decision-making behaviour of medical students or practitioners exposed to such courses? Those involved know only too well how difficult such courses are to design and evaluate since the connection between ethics education and practice is not known and may never be demonstrated to the satisfaction of critics. Critics not only seek answers to the questions of whether the teaching of bioethics makes a difference, which is a fair question, but they also seek answers to the question of whether bioethics should be taught in medical schools. Can bioethics be taught? Whose bioethics is being taught? What does the trained bio-ethicist contribute? Some of these questions arise from misunderstanding and some reflect the still too dominant view in medical schools which divides disciplines into those which provide ‘practical skills’, and those which contribute only theoretical and therefore peripheral knowledge. The authors will address these questions in the light of their experience at Newcastle, Australia, where the Faculty of Medicine has been teaching bioethics for over a decade.     

Psychometric characteristics of the objective structured clinical examination

The objective structured clinical examination (OSCE) is increasingly being used as a method of clinical assessment yet its measurement characteristics have not been well documented. Evidence is accumulating that many OSCEs may be too short to achieve reliable results. This paper reports detailed psychometric analyses of OSCEs which were administered as part of a well-established final-year examination. Generalizability theory guided investigation of test reliability. At the present test length the OSCE components showed low reliabilities relative to written components. Satisfactory reliabilities could potentially be achieved if test length was increased to approximately 6 hours, a time which would create significant logistic problems for most medical schools. Several strategies for dealing with this practical problem have been explored. Firstly, it was shown that more careful selection of stations based on their psychometric characteristics can significantly improve reliability. Secondly, where rater availability is a limiting factor to increasing test length, more can be gained by using one rater per station and having more stations than using two raters per station. Finally, OSCE scores can, with advantage, be combined with other test scores which are obtained by using less resource-intensive methods. By adopting such strategies, a reliable assessment of clinical competence could be obtained in about 4 hours of testing time which was equally divided between an OSCE constructed of practical and clinical stations and a written test.     

Performance of medical students in case-based and essay components of written anatomy examinations

This paper reports on second-year medical students' performance in the case-based and traditional essay components of the gross anatomy written examinations at the University of Otago held at the end of 1988 and 1989. The mean marks for these two components of the examinations are presented for the three main categories of student entry. Differential performance on the case-based component relative to the essay component has been determined for each student in the class and ranked in order. The proportions of students in the three entry categories falling in the various quartiles for the class are given. The data show that when an intensive programme of case-based learning was followed, as in 1988, all three categories performed similarly on the case-based component relative to the essay component. When a less intensive programme of case-based learning was used, as in 1989, the differential performance of the preferential undergraduate and graduate categories was different to each other. The findings suggest that the achievement of students in the case-based projects is dependent upon the organization of the programme and the extent to which students and staff become involved in the projects. The writing of reports on the cases by students for assessment in 1988 may have had an important influence on the outcome for this year.     

Community-oriented medical education: comparison of tracks in Mexico and New Mexico

Most major innovations in medical education have occurred in a small number of new schools. Attempts to create change in traditional schools are far more complex. Relevant models for such change are few and there is an urgent need for institutions pioneering such changes to learn from each other's experiences. Two conventional medical schools described in this paper have attempted to create community-oriented institutional change by establishing experimental undergraduate curricular tracks. One is in a developing country, Mexico, the other in a technically developed country, the United States. These new tracks in medical education evolved independently of one another, yet they have many similarities and have experienced common problems. A formal exchange between the two schools has led to new insights in medical education and improvements to both programmes. Exchange agreements like the one reported here would be valuable for other medical schools in both developing and technically developed countries.     

Library use and academic achievement among medical students

Many factors play a part in determining the performance of students in examinations, but the extent to which students use library facilities does not appear to have been recently considered as a factor, in medicine or in any other academic subject. In this study, the number of books borrowed from the library by undergraduate medical students was used as a simple measure of library use, and significant differences in book-borrowing levels were found between students in different years of the medical course, students from different regions of the world, and men and women students. In the first year of the course, students who borrowed most also performed best in their end-of-year examinations, and this association was only partly explained by regional differences. No such association was found among final-year students, suggesting different study habits and different assessment criteria in the clinical years of the course.     

The essential role of the student in curriculum planning

Medical school curricula are planned, written and organized by academic and clinical staff within medical schools. While these medical educators may well be experts in their given field, they lack first-hand experience of what it is to be a medical student in 1995. For a medical curriculum to be an effective means of learning for today's students, it must be written with a knowledge of their priorities, needs and abilities. The way in which this can be best achieved is by the inclusion of current students in all stages of designing a new curriculum.
In my second year of medicine at Flinders University, I became involved in planning for the new Graduate Entry curriculum. In the role of student advocate, I have found I am able to offer teaching staff a unique perspective, the student perspective , on various issues.
Students, through experience from their own education, are able to give advice on student resources and facilities and are in a favourable position to judge other aspects of curricula, such as the balance and relevance of course content and assessment. Students need to realize the valuable insight they have to offer their faculties and the way in which this can benefit future students. It is by actively seeking student involvement and using their input, that faculties will be able to create a consumer-friendly curriculum.     

Elaborated learning in undergraduate medical education

Southampton Medical School holds its major examination of basic knowledge after rather than before students enter their first clinical attachments. An interview survey investigated its educational effects, and found that students adopt one of four revision approaches. The most successful, not just in terms of examination grade but more particularly in students' subsequent ability to retrieve and use the knowledge gained, occurred when students related their preclinical revision to their clinical experiences. One of these approaches, an elaboration of knowledge, is considered to be essential for effective clinical thinking yet is probably rare elsewhere in medical education since it appears to be a consequence of a particular curricular arrangement. An explanation is given in terms of current thinking in cognitive psychology, and this challenges the theoretical assumptions on which other research in medical education has been uncritically based. Some implications for medical education and further research are discussed.     

Identifying core skills for the medical curriculum

A survey was undertaken at the University of Sheffield Medical School to identify clinical and other professional skills which are required on graduation and to assess whether and when these skills have been acquired. The purpose of the survey was to identify core practical skills, defined as skills which the majority of clinical firms require and which, in addition, were used by the majority of Pre-registration house officers (PRHOs). The survey was conducted by questionnaires which were circulated to the following four sample groups (number in sample: % response rate): (1) consultants in clinical firms taking undergraduates and post-graduates from Sheffield Medical School (63: 75%); (2) house officers starting their pre-registration year (118: 52%); (3) house officers ending their pre-registration year (120: 43%); and (4) undergraduates starting their final year (110: 65%). The questionnaire contained a stimulus list of 31 clinical and four personal skills with an opportunity for respondents to list other skills they felt to be important. Of the 35 skills listed on the questionnaire, 26 were identified as core practical skills. Fifteen of the core skills had been acquired by the majority of students by the time they graduated, 13 of which were acquired prior to the final undergraduate year. Core skills not acquired as an undergraduate were acquired as a PRHO. The survey acted as a quality control mechanism for teaching at both undergraduate and post graduate levels and provided the basis of a medical school core of practical skills on the basic medical education continuum.     

Measuring clinical competence of medical students

Evidence of clinical competence for medical students entering the clinical clerkships at the University of Kansas College of Health Sciences is established by passing two different examinations: a 100 item multiple choice examination and a videotaped history and physical examination by each student of a simulated patient, being rated by that patient and two examiners. In 1976 the class of 196 medical students took an average 1.85 written examinations per student. With 70% or better constituting a passing score, 30.6% passed on the first attempt, 55.6% the second, 11.2% the third and 2.5% the fourth. Each student passed the televised practical examination and had the opportunity to review his or her videotape with a critiqued data base and the examiners' and simulated patient's evaluations in hand. Correlation coefficients for all 196 students between scores of written examinations, medicine tutors, examiners and professional patients revealed weak but significant correlations between the assessments of examiners and medical tutors and assessments of examiners and written examination scores, but not between other evaluations. This scheme of proof of competence appears to be objective and direct, and serves the convenience of both students and teaching staff.     

Medical teaching of the cultural aspects of ethnic minorities: does it exist?

The development of published material relating to the practice of medicine in multiracial and multicultural Britain is briefly reviewed. The utilization of such information in English medical schools is found to be absent or at a low level of priority. A more detailed study of one region demonstrates that junior hospital doctors believe from experience that they have a need for training in 'multicultural' medicine to serve their current patient load. Objective tests demonstrate the poor levels of knowledge and the role of practical experience. Responses from a survey of administrators and clinical tutors suggest interest or willingness to develop training in this field but a lack of coordination or resources. The paper demonstrates clearly that medical education has failed to keep pace with developments in the social and ethnic composition of the potential client population. Doctors who are practising in multiracial areas support this argument for changes in the undergraduate curriculum and extension of provision in postgraduate education. These improvements should not be confined to specific medical schools because of the career mobility of doctors, and by analogy could be extended to other medical professionals. Recommendations are made as a basis for a long-term strategy to ensure that medical education plays its part in combating racism in society.     

Literature and medicine: a short course for medical students

A course on literature and medicine for medical students is described. A wide range of books, plays and poems were used with medical and non-medical themes. Students enjoyed the course and particularly welcomed the non-medical components. The staff learned at least as much as the students. Several book lists were developed with input from the students. Such a course might have a part to play in several parts of the medical course, such as in the teaching of ethics.     

Introducing medical students to medical informatics

Summary. Medical informatics ( MI ) has been introduced to medical students in several countries. Before outlining a course plan it was necessary to conduct a survey on students' computer literacy. A questionnaire was designed for students, focusing on knowledge and previous computer experience. The questions reproduced a similar questionnaire submitted to medical students from North Carolina University in Chapel Hill ( NCU ). From the results it is clear that although almost 80% of students used computers, less than 30% used general purpose applications, and utilization of computer-aided search of databases or use in the laboratory was exceptional. Men reported more computer experience than women in each area investigated by our questionnaire but this did not appear to be related to academic performance, age or course. Our main objectives when planning an MI course were to give students a general overview of the medical applications of computers and instruct them in the use of computers in future medical practice. As our medical school uses both Apple Macintosh and IBM compatibles, we decided to provide students with basic knowledge of both. The programme was structured with a mix of theoretico-practical lectures and personalized practical sessions in the computer laboratory. As well as providing a basic overview of medical informatics, the course and computer laboratory were intended to encourage other areas of medicine to incorporate the computer into their teaching programmes.     

Should medical students act as surrogate patients for each other?

Until recently, most clinical teachers and medical students have regarded using medical students as surrogate patients for peer teaching of physical examinations and clinical skills as practical and uncontroversial. Recent changes to medical curricula and changes in hospitalized patient populations have led to questions about the ethical acceptability of this practice. This paper explores the ethical issues inherent in the use of medical students as surrogate patients. It suggests that, ethically, there are parallels with two situations: when students conduct physical examinations on patients and when students participate as subjects in research. Drawing on accepted ethical practice in these two germane areas, the paper argues that there are both ethical strengths and weaknesses in the practice of using students as surrogate patients. Strategies to promote free and informed involvement of students as surrogate patients are suggested.     

Interprofessional clinical education of medical and pharmacy students

Pharmacists have become increasingly involved in influencing prescribing. Pharmaceutical education has changed accordingly, with increased teaching in therapeutics, partly on hospitals wards, giving students an insight into diseases and helping communication with clinicians. To extend this idea we have designed joint therapeutics teaching sessions with pharmacy and medical students. The scheme involves final year pharmacy students who have completed a course in clinical pharmacy and medical students who have completed their second MB. Interdisciplinary pairs of students are assigned a patient with common medical and therapeutic problems, such as arthritis, diabetes and cardiac failure; patients on multiple drug treatments are preferred. They jointly obtain a history: the medical student performs basic clerking, while the pharmacy student obtains the medication history. The medical student subsequently presents a brief medical history, with a summary of the patient's current problems. For each problem, the pharmacy student presents the current therapy, its rationale and how it is to be monitored. Experience with 73 students over 3 years has shown that almost all found sessions with students from another discipline useful. Few felt that members of the pairs contributed unequally. The main problem appeared to be insufficient time (although 2 1/2 h were allowed). Most students favoured more such sessions. Little difference in ability appeared between the two disciplines; there was considerable co-operation and little nascent 'professional rivalry'. The medical students were more comfortable interviewing patients, and the pharmacy students more confident analysing drug therapy. It is concluded that such interdisciplinary sessions are a successful method of clinical teaching and should be encouraged.     

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.     

Theoretical versus practical orientations in pre-clinical biochemistry teaching

A pre-clinical lecture on the relevance of biochemical theory to clinical practice may adopt either a theoretical or a practical orientation. These two approaches were compared in an experiment involving seventy-one second-year medical students. Theory-orientated teaching was superior for promoting recall, while neither method showed overall superiority for promoting application. These results suggest hypotheses for future research.     

Where should special attention be paid in undergraduate medical education? Two surveys among Finnish doctors

The study focuses on Finnish doctors' views of their undergraduate medical education. In 1988, a study (Junior Physician 88 Study) involving all the doctors registered during the years 1977–1986 in Finland (n = 5208 ) was carried out. A questionnaire was sent to a random sample of 2632 doctors, and after two mailings 1745 questionnaires (66.3%) were returned. A total of 1334 gave at least one answer to the question: ‘Where should special attention be paid in undergraduate medical education?’ Five years later, in 1993, another study (Physician 93 Study) involving all medical doctors registered in Finland during the years 1982–1991 (n = 4671 ) was carried out. The same questionnaire was sent to a random sample of 2332 doctors, and after two reminders 1818 questionnaires (78.0%) were returned, and 1228 doctors also answered the open-ended question. Content analysis was used to analyse the answers qualitatively and quantitatively. About 90% of the answers could be classified into two main categories: practical skills and evaluation of subjects. The most common proposal for the improvement of undergraduate medical education was that the practical skills needed in general practice should be taught. More education in administration and health economics was also desired. Respondents said that preclinical and clinical studies should be more closely integrated. In answers to the open question, the course in public health was strongly criticized for being too theoretical. Learning of the core knowledge for medical practice was considered essential.     

Consistency of teaching in parallel surgical firms: an audit of student experience at one medical school

BACKGROUND: Traditional clinical clerkships have been based on the apprenticeship model of learning, with opportunistic teaching by doctors on presenting patients. Students at King's College School of Medicine, London had expressed concern that they were receiving inequitable experiences in different clerkships. This had become more apparent since the introduction of a school-wide end-of-year skills assessment. We decided to assess the consistency of delivery of the surgical syllabus. METHOD: A multistage questionnaire survey was undertaken with third-year (first clinical year) undergraduate medical students on surgical clerkships. The questionnaire required students to record topics about which they had been taught, and practical skills on which they had been supervised, from the surgical syllabus pertaining at the time. RESULTS: 194 (46.4%) questionnaires were returned. A low level of consistency was reported in the teaching of theoretical topics and practical skills across surgical clerkships in eight different locations. There were substantial differences, both in overall coverage of the syllabus and in the priority given to different topics. There were no overall differences between teaching hospital- and district general hospital-based clerkships. DISCUSSION: Students in so called 'parallel' clerkships did not receive comparable teaching. The traditional opportunistic nature of clinical teaching led, in effect, to individual curricula within each clerkship. The General Medical Council has called for a core curriculum to be delivered across different clinical sites within each medical school. To achieve this, medical schools may need to introduce guidelines to direct teaching in the same way that clinical protocols have been developed to achieve greater standardization in clinical practice.