Fear of death and dying in medical students: effects of clinical experience

Changes in the perception of death and dying during medical training were assessed, to test the hypothesis that fear is increased by exposure to dying patients. In general, clinically experienced medical students did not consistently differ from clinically inexperienced students in the intensity of fear of death. The two groups did differ in the frequency with which they thought about death. Students with clinical experience reported thinking more frequently about their own dying process and about interacting with a dying patient.     

Effects of cadaver dissection on the attitudes of medical students

Summary: Summary. A study was conducted to determine whether the attitudes of medical students to death and caring changed during the 3 months following exposure to cadaver dissection. All first-year students were invited to complete a questionnaire immediately before their initial cadaver dissection experience, after 6 weeks, and after a further 3 months. The questionnaire reflected attitudes to death, violent death, death of someone known to the respondent and caring when someone known to the respondent is seriously injured. Ethnicity and previous exposure to dying has no effect on responses, but overall men students' reactions were significantly less than for women ( P < 0.001). The responses given on the final part of the questionnaire after 3 months were significantly lower than those to most questions in the first part of the questionnaire. The exceptions were those questions where the subject in the given scenario was known to the respondent, where reactions were rated significantly greater ( P < 0.001) in the follow-up questionnaire and can be explained on the basis that they were a personal referent.
Students rapidly develop a coping mechanism which enables them to view cadaver dissection as an occupation quite divorced from living human beings. During these early months of training solicitude decreases for those who die who are unknown to them, but concern for personal referents increases. Educators should be aware of the dramatic change of attitudes among students and the process of professionalization which might influence their caring of future patients.     

Inner city deprivation and medical education: a survey of medical students by medical students

A total of 330 preclinical and clinical medical students and house officers at St Mary's Hospital were surveyed by questionnaire to assess their knowledge and experience of inner city deprivation and health, and their opinions on the role of the doctor in responding to these problems. The response rate was 87%. Over 75% of the respondents had had no experience of inner city living conditions before coming to medical school, and they gained little experience during the medical course until well into the clinical years. Most preclinical students wanted more contact with the community early in the course; less than one-third of the clinical students wanted this. The differences in knowledge and attitudes between the year groups are discussed and possible reorientation in medical education is considered.     

Medical students' perceptions of their educational environment: expected versus actual perceptions

Objective To compare Year 1 medical students' perceptions of their educational environment at the end of Year 1, with their expectations at the beginning of the year using the Dundee Ready Education Environment Measure (DREEM). Methods Year 1 students (n = 130) at the University of East Anglia Medical School were asked to complete the DREEM during their induction week at the beginning of Year 1, thinking about the educational environment they expected to encounter (Expected DREEM), and again as part of a compulsory evaluation at the end of Year 1, thinking about the educational environment they had actually experienced (Actual DREEM). A total of 87 students (66.92% of the starting cohort) completed the DREEM on both occasions and gave permission for their data to be published. Results The Expected DREEM score was 153 out of a maximum of 200, and the Actual DREEM score was 143. Student's expected perceptions of learning and teachers, and their expected academic self- and social self-perceptions were all more positive than their actual perceptions. There was no difference between expected and actual perceptions of atmosphere. Specific aspects of the educational environment showing dissonance were identified. In some areas students' low expectations had been matched by their actual experience. Conclusions Medical students had started Year 1 with expectations about the educational environment that had not been met. However, areas showing dissonance received low item scores on the Actual DREEM and as such would be picked up for remediation, even without information about student expectations.     

Factors influencing the communication skills of first-year clinical medical students

The aim of this study was to examine the factors influencing medical students' communication skills. The sample comprised all first-year clinical students. Thirty-two received teaching in communication skills during the year; the remaining 56 did not. Students' career preferences, attitudes towards communication skills and confidence in their ability to communicate with patients were assessed by questionnaire at the beginning and end of the year. At the end of the year each student was videotaped interviewing a simulated patient. Students' communication skills were assessed on the basis of this interview by raters using a standardized rating scale, and by patient questionnaires. While there was some evidence that brief communication skills training improved skills, sex of student was a more significant predictor of level of skill. Students who perceived communication skills as less relevant to medicine and those who were more confident about their own communication skills were more likely to prefer a career in hospital medicine. Students' judgements of their ability to communicate effectively were poor. In the main there was no relationship between confidence and level of skill: where they were related, the association was negative. The benefits from communication skills training might be enhanced by involving hospital doctors in the teaching, and providing students with detailed video feedback on their skills at the outset.     

Students'' attitudes towards psychiatry

Using a reliable measure, a self-administered questionnaire (ATP), and adequate numbers of students, this study demonstrates the negative effects of general medical/surgical training and the positive effect of the psychiatry clerkship on students' reported attitudes towards psychiatry. A negative view of psychiatry at the beginning of the clerkship may make students reluctant to improve their interview skills but is otherwise unimportant in determining their reactions and performance in the clerkship. Medical students' interest in psychiatry as a career increases during the psychiatry clerkship but this merely offsets the decline in interest that occurs at other stages during the clinical training. Much of the attitudinal change that occurs during the psychiatry clerkship is maintained into the pre-registration year but the housemen recorded a significant negative change on the items concerning efficacy of psychiatric treatment and attitudes towards psychiatric patients. Additional training by psychiatrists during the pre-registration year might increase the motivation of young doctors to detect and treat psychiatric illness which they will encounter in all branches of medicine.     

Attitudes of medical students to old people: a cross-national comparative study

Medical students' attitudes to the elderly were compared at the start and finish of a 5-week clinical attachment in health care of the elderly at the Christchurch School of Medicine. The study investigated students in their first clinical year (fourth year of their medical course) over five terms using a questionnaire employing a Rosencranz-McNevin semantic differential scale to measure general attitudes to old age and a Likert scale to measure attitudes to medical care. A question was also asked about career preferences. There was significant improvement in attitudes measured by both scales (Rosencranz-McNevin P less than 0.001, Likert P less than 0.001). Students also showed an increase in interest in health care of the elderly as a career choice. When compared with two cohorts of students from Nottingham Medical School, attitudes were significantly better in the Christchurch group at the commencement of the run. Students at both schools showed an improvement in knowledge but this was more marked for Christchurch students.     

Teaching patient wellness to first-year medical students: the impact on future ability to perform the history of present illness

OBJECTIVES: Curriculum innovations to improve clinical skills have been implemented at many American medical schools. A current curricular change at the University of Connecticut School of Medicine involves teaching wellness to students in the first year rather than the more traditional focus on disease processes. It is unknown, however, if focusing on wellness detracts from students' future ability to perform the history of present illness (HPI) which requires students to focus on disease processes. DESIGN: The current study examined this issue by comparing two cohorts' clinical skills (n=156), with one class participating in a traditional curriculum during their first year and the other in a revised curriculum teaching wellness during the first year. Each class was evaluated at the beginning of their second year to determine their level of clinical competence. SETTING: University of Connecticut School of Medicine SUBJECTS: Second-year medical students. RESULTS: Analyses suggested that teaching wellness did not detract from future ability to perform an HPI, and in fact students taught wellness had significantly higher history-taking scores. CONCLUSIONS: Curricular innovations which stress wellness and prevention early in medical education do not detract from and may enhance students' ability to perform the history of present illness later during medical training.     

An appraisal of medical students' reflection-in-learning

INTRODUCTION: How do students reflect as they strive for some control of learning early in their clinical activities? The purpose of this study was to examine the reflection-in-learning profile of medical students as they started their clinical apprenticeship. METHODS: A measure of reflection-in-learning was used to appraise the level and direction of change of reflection in relation to a course experience. The study involved 103 medical students of both sexes who were beginning clinical activities. Assessments of self-regulation of learning, of the meaningfulness of the learning experience, and of diagnostic thinking were also obtained. RESULTS: The results showed that 81% of the students had an increase in scores for reflection-in-learning between the beginning and the end of a course. At the end of the course, the level of reflection-in-learning was significantly associated with self-perceived competence for self-regulated learning and with the meaningfulness of the learning experience. In the following term, students who had high reflection-in-learning scores at the end of the course had higher grade-point averages and greater self-reported diagnostic ability in comparison with those with low scores. CONCLUSIONS: There was some evidence of an improved quality of reflection as the students strive for some control of learning. Overall, the findings support the idea that a greater effort at reflection is associated with a more positive learning experience. They also suggest that reflection-in-learning is related to readiness for self-regulation of learning and may be conducive to enhanced diagnostic ability. In conclusion, measuring reflection-in-learning may be a useful tool in the appraisal of medical students' learning profiles.     

Medical students' attitudes toward patient-centred care: a longitudinal survey

PURPOSE: Patient-centredness should be at the heart of medical education. This longitudinal study aimed to assess possible attitude changes towards patient-centredness in a medical students' cohort as they progressed through the clinical curriculum. It also investigated the possible impact of socio-demographic factors on students' attitudes. METHODS: The same student cohort was tested on 2 occasions: during their initial exposure to clinical curricula (year 4) and after 2 years, at the end of the clerkship (year 6). Students completed a questionnaire including demographics and the 18-item Patient-Practitioner Orientation Scale (PPOS). PPOS differentiates between patient-centred versus doctor-centred or disease-centred orientation, measuring attitudes along 2 dimensions: 'sharing' and 'caring'. RESULTS: A total of 483 fully completed questionnaires was returned (response rate 83%). The cohort's attitudes were significantly more doctor-centred at the end of their studies compared to the beginning of their clinical curricula (P < 0.001). However, regarding the caring part of their relationship with patients, they maintained a satisfactory level of patient-centredness. Concerning sharing information, female students were significantly more patient-centred at year 4, with their mean score decreasing at the end of their clerkship. Furthermore, among only female students, having a looser relationship with religion was associated with more patient-centred attitudes. CONCLUSIONS: Increased authoritarianism in graduating students' attitudes emphasises clearly the need for future research and redesigning communication curricula. Furthermore, the influence of gender and relationship with religion on attitudes towards the doctor-patient relationship should be explored further, in order to eliminate disparities in the provision of patient-centred medical care.     

A comparison of the educational opportunities on junior medical attachments in general practice and in a teaching hospital: a questionnaire survey

OBJECTIVES: To obtain students' perceptions of the educational quality of the general internal medicine teaching overall and to determine whether specific learning objectives were better addressed in general practice or in hospital. DESIGN: The survey was carried out after a 10 week block of general internal medicine, consisting of five weeks taught in general practice and five weeks taught in a teaching hospital. Students were randomly allocated to start in either general practice or hospital. The outcome measure was a questionnaire survey of students perceptions' of their learning on the two halves of the block. Each student completed the same questionnaire twice: once after their hospital experience and once after their general practice experience. Statistical Analysis was carried out using the SPSS package for Windows 3.1. Group means were calculated for each response, and the mean differences for each student's responses for the two learning environments were analysed using t-tests for paired samples. SETTING: Royal Free and University College Medical School at University College London. SUBJECTS: The study population was the entire annual intake (n = 225) of students into the first clinical year at one UK medical school. RESULTS: Students perceived they learnt more about history taking and physical examination in the community, whereas they learnt more about writing up their clerkings, keeping progress notes and disease management in hospital. CONCLUSIONS: The community and hospital environments appear to have different strengths for the teaching of medical students. These data support judicious transfer of clinical skills teaching from teaching hospitals into general practice, when the circumstances achieved here can be duplicated. However, some aspects of the clinical attachment, particularly record keeping and disease management, are probably better taught in hospital at present.     

Social issues in medicine: a follow-up comparison of senior-year medical students'' attitudes with contemporaries in non-medical faculties

A comparison of first-year medical students' attitudes to social issues in medicine with attitudes of non-medical first-year students in 1983 found that the medical group was less conservative towards general social issues but more conservative in relation to those areas which closely affect the doctor's role, particularly the place of allied health professions and government intervention in health care. This paper reports a follow-up study of the same groups of students when they had reached senior years in their respective courses. While medical student conservatism on general social issues continues to be no greater than other student groups there is a marked increase in conservatism of attitudes towards government involvement in health care and regulation of costs. Attitudes to allied health professions and preventive care remain unchanged but senior medical students are significantly less likely to recognize social factors as determinants of illness than they were when they commenced the study of medicine. Specific curricular attention to social and behavioural medicine does not appear to counteract the predominantly biomedical perspective students experience in teaching hospitals, the major venue for their clinical education.     

Humanities in medical education: rationale and resources for the dissection laboratory

Dissection of a human body during an anatomy course raises for first-year medical students questions about invasion of privacy, cadaver sources, dying and death. Emotions evoked are often heightened by the fear and uneasiness each student experiences when dissecting the body of a human being. Providing curricular resources for identification and discussion of reactions to death and dissection early in the first year can demonstrate to students the humanity of having such reactions, and that these reactions can be understood and managed more or less appropriately. An elective course has been offered to first-year medical students at the University of Massachusetts Medical School for 10 years; the students' reception of this evolving programme has been enthusiastic. The rationale, content, resources and responses of such a course are presented.     

The anxieties of new clinical students

The specific anxieties of 74 medical students beginning their clinical training were assessed by means of a questionnaire at the start of the clinical introductory course at St Mary's Hospital Medical School, London. Situations differed in the amount of anxiety that they engendered, and students also differed in the number of situations that they found anxiety producing. Students particularly reported that interactions with senior staff on ward rounds were anxiety provoking. The same questionnaire was also distributed to 52 teaching hospital doctors who were asked to complete the questionnaire as they thought the students had done. Compared with students, the doctors considered more situations to be anxiety provoking, and they differed in their rank ordering of the situations. Doctors tended to overestimate anxiety concerning communication problems, and to underestimate anxiety concerning routine clinical tasks such as phlebotomy.     

Students' attitudes towards computer testing in a basic science course

OBJECTIVES: The introduction of computerized testing offers several advantages for test administration, however, little research has examined students' attitudes toward computerized testing. This paper, reports the attitudes of 202 students in a first year cell biology and histology course toward computerized testing and its influence on their study habits over a three year period. DESIGN AND METHODS: Multiple choice and image-based extra credit examinations and summative image-based examinations have been successfully administered in the course. The results indicate that students readily accept computer exams and that their study habits were influenced in a positive manner by the computer administered extra-credit examinations. RESULTS: Our results provide further evidence that medical students like the use of computer administered examinations and that the examinations may actually accentuate the learning experience.     

Medical students'' evaluations of different levels of medical ethics teaching: implications for curricula

Although medical ethics has become a part of the curriculum of almost every medical school, medical students' perceptions of the value of medical ethics have not been documented. This paper reports the evaluations given by 137 preclinical and 216 clinical medical students to different levels of medical ethics teaching at the College of Human Medicine and the College of Osteopathic Medicine of Michigan State University. The results indicate (1) that students' satisfaction with medical ethics teaching is directly linked to how much they receive, (2) that students overwhelmingly prefer the input of both ethicists and doctors to teaching by either alone, and (3) that a preclinical medical ethics course followed by explicit medical ethics teaching in clinical training is a promising model for achieving an adequate level of medical ethics teaching within medical education.     

The effect of a Structured Question Grid on the validity and perceived fairness of a medical long case assessment

PROBLEM: A perception that the reliability of our oral assessments of clinical competence was vitiated by lack of consistency in questioning. DESIGN: Parallel group controlled trial of a Structured Question Grid for use in clinical assessments. The Structured Question Grid required assessors to see the patient personally in advance of the student and to write down for each case the points they wished to examine. The Structured Question Grid limited assessors to two questions on each point, one designated a pass question and one at a higher level. Three basic science and three clinical reasoning issues were required, so that a total of 12 questions was allowed. SETTING: Small (70 students/year) undergraduate medical school with an integrated, problem-based curriculum. SUBJECTS: Sixty-seven students in the fourth year of a 5-year course were assessed, each seeing one patient and being examined by a pair of assessors. Assessor pairs were allocated to use the Structured Question Grid or to assess according to their usual practice. RESULTS: After the assessment but before being informed of the result the students completed a questionnaire on their experience and gave their performance a score between 0 and 100. The questions asked were based on focus group discussions with a previous student cohort, and concerned principally the perceived fairness and subjective validity of the assessment. The assessors independently completed a similar questionnaire, gave the student's performance a score between 0 and 100, and assigned an overall pass/fail grade. CONCLUSIONS: No difference was detected between students' or assessors' views of the fairness of the assessment for assessors who had used the Structured Question Grid compared to those who had not. Students whose assessors used the Structured Question Grid considered the assessment less representative of their ability. No difference was detected in the chance of students being assessed as failing or on the likelihood of a discrepancy between students' and assessors' ratings of students as passing or failing.     

The value of student-made models as learning aids in physiology

In a new educational scheme introduced in Malta in 1978, university students spend half of the academic year studying and the other half as workers in various departments. During their work phase, students designed and made working models as teaching aids for the study of physiology. The value of these models was assessed on another group of students before they started their physiology course. These students completed a multiple choice questionnaire on three occasions: before and after having seen the models and after they had had them explained. In addition, they completed a questionnaire designed to elicit their views concerning these models. It was found that the models effectively improved knowledge with little staff involvement. The effectiveness of a model as an aid to learning was directly proportional to the degree of its appeal, but inversely proportional to its complexity in terms of stimulating factors. It is suggested that such models could help in teaching, compensating for shortage of staff, and that students' ability to produce teaching models should be wisely exploited.     

Specialty choice and understanding of primary care among Japanese medical students

To assess specialty choice and understanding of primary care among Japanese medical students, all students from seven Japanese medical schools (three public and four private) were surveyed, using a written questionnaire. A total of 3377 students provided data for the study. Of the students surveyed, 89.8% wanted to become clinicians, and 79.3% wanted to have general clinical ability. About half of the respondents, 54.9%, replied that they had some, or great, interest in primary care, but it was found that their understanding of primary care was inadequate. Almost half (56.3%) of the students answered that they had some idea of what a general practitioner did. This proportion was nearly the same through all years of medical school. While 1245 (36.9%) students (most of them in the fifth or sixth year) replied that they had received some clinical training while working in hospitals, only 203 (6.0%) students had worked in private clinics (the sites where most primary care is still provided), and 129 (3.8%) students had experience in providing home visits and home care. An even greater number, 64.3%, replied that they had inadequate information about the career options available to them. The study found that although many Japanese medical students want to obtain broad clinical competence, their understanding of primary care is insufficient. In order to increase the number of primary care providers the system of medical education in Japan must provide primary care doctors to act as role models, and must make available information about postgraduate primary care programmes. These programmes need to be increased, as do rewarding positions for programme graduates.     

Undergraduate medical students' views about a reflective portfolio assessment of their communication skills learning

INTRODUCTION: To date, no studies have examined preclinical medical students' views about portfolios. Since portfolios are becoming increasingly valued in medical education, this study explores second-year medical students' views about a reflective portfolio assessment of their communication skills. METHODS: 178 second-year medical students at the University of Nottingham completed the 18-item reflective portfolio questionnaire (RPQ) (alpha = 0.716) and a personal details questionnaire three days before submitting their portfolio assessment for communication skills. Data were analysed using univariate and multivariate statistics on SPSS Version 10.0. RESULTS: Total scores on the RPQ ranged from 40 to 75 (mean 58.28, SD 7.08). Significant relationships existed between RPQ total scores and students' ratings of their reflection skills (rs = 0.322, P < 0.001), RPQ total scores and students' confidence building another portfolio (T = 4.381, d.f. = 176, P < 0.001), and RPQ total scores and students' marks for their reflective portfolio assessment (rs = 0.167, P = 0.029). Students with more positive views about reflective portfolios were more likely to rate their reflection skills as good, receive better marks for their portfolio assessment, and be more confident building another portfolio. DISCUSSION: This study begins to highlight preclinical medical students' views about reflective portfolios. However, further research is required using qualitative studies to explore students' views in depth. Medical educators should be encouraged to consider introducing portfolios as a method of formative and summative assessment earlier in the medical curriculum.