The first batch of graduates of a new medical curriculum in Asia: how their teachers see them

OBJECTIVE: To examine teachers' views of the first batch of graduates of a revised medical curriculum in Asia. METHODS: A cross-sectional study using a structured questionnaire was carried out to obtain the views of all the clinical teachers involved in teaching final year students of the old curriculum in 2000-01 and the new curriculum in 2001-02 at the University of Hong Kong, which commenced curricular reform in 1997. RESULTS: Nearly 62% of respondents felt that better graduates were being produced with the new curriculum. The majority of them rated the new curriculum students better in nearly all the major goals of the new curriculum, such as self-directed learning initiative, problem solving skills, interpersonal skills and clinical performance in patient care. However, the core knowledge of the new curriculum students was of concern to some teachers. CONCLUSION: This study focused on the first complete cycle of a revised medical curriculum in Asia. Teachers' views of the new curriculum students were highly positive and they felt that better graduates were being produced.     

Teaching and learning in the clinical setting: a qualitative study of the perceptions of students and teachers

Objective  To describe the perceptions of medical students and clinical teachers of teaching and learning in the clinical setting.
Design  Qualitative study of focus groups with undergraduate medical students and semistructured interviews with hospital consultant clinical teachers.
Setting  The School of Medicine, University of Leeds and the Leeds Teaching Hospitals Trust, UK.
Participants  Fourth year medical students and consultant clinical teachers.
Main outcome measures  Analysis of narratives to identify students' perceptions of clinical teaching and consultants' views of their delivery of undergraduate clinical teaching.
Results  Students believed in the importance of consultant teaching and saw consultants as role models. However, they perceived variability in the quality and reliability of teaching between physicians and surgeons. Some traditional teaching venues, especially theatre, are believed to be of little clinical importance. Generally, consultants enjoyed teaching but felt under severe pressure from other commitments. They taught in a range of settings and used various teaching strategies, not all of which were perceived to be 'teaching' by students.
Conclusions  While students and teachers are educational partners, they are not always in agreement about the quality, quantity, style or appropriate setting of clinical teaching. To enable teachers to provide more high quality teaching, there needs to be support, opportunities and incentives to understand curricular developments and acquire teaching skills.     

Impact of a new curriculum on medical students' interpersonal and interviewing skills

OBJECTIVES: In 1998 we reported on the rise and fall of medical student communication skills during the 4 years of medical school. Since then, the University of Connecticut School of Medicine has completed a major curriculum renewal project with an emphasis on early clinical work, lifelong learning and more ambulatory training. The goals of this study were to compare students' interviewing and interpersonal skills in standardised patient (SP) assessments in the old and new curricula and to assess the success of the new curriculum in preventing a decline in student skills in this domain. METHODS: The clinical skills of 202 students were measured longitudinally during encounters with SPs in each of their 4 years of medical school. Students in this study and the earlier study were evaluated using the Arizona Clinical Interviewing Rating (ACIR) Scale. RESULTS: Compared with students from the previous curriculum, students on the new curriculum in this study showed an improvement in ACIR scores. Year 1 mean ACIR scores (1 = poor to 5 = excellent) were, respectively, 3.6 for the old curriculum cohort and 4.0 for the new curriculum group. In Year 4 the mean score for the old curriculum cohort was 3.7 and that for the new curriculum group was 3.8. Students on the new curriculum still showed a decline in ACIR scores from Years 1 to 4, but it was not as severe a decline as it had been previously. CONCLUSIONS: Pre-clinical medical students perform better on measures of interpersonal communication than their clinical counterparts. The students who participated in the new curriculum demonstrated an earlier acquisition of and a less steep decline in interviewing and interpersonal skills during the course of medical school.     

Meeting the challenge of prescribing and administering medicines safely: structured teaching and assessment for final year medical students

OBJECTIVES: To promote safe prescribing and administration of medicines in the pre-registration house officer (PRHO) year through a programme of structured teaching and assessment for final year medical students. DESIGN: Forty final year medical students from two medical schools were randomly allocated either to participate in a pharmacist facilitated teaching session or to receive no additional teaching. Teaching comprised five practical exercises covering seven skills through which students rotated in small groups. One month later, a random sample of 16 taught and 16 non-taught students participated in a nine-station objective structured clinical examination (OSCE) to assess the impact of the teaching. SETTING: Manchester School of Medicine (MSM), and Kings College School of Medicine and Dentistry (KCSMD). PARTICIPANTS: Final year medical student volunteers. MAIN OUTCOME MEASURES: The need for teaching as indicated by student prior experience; questionnaire rating of student acceptability of teaching and assessment; self-rating of student confidence post-assessment, and student performance assessed by OSCE. RESULTS: The study demonstrated that the taught group achieved higher scores in eight OSCE stations. Four of these were statistically significant (P < or= 0.005). Taught students felt more confident performing the skills on five stations. From 0 to 47.5% students had prior experience of the skills taught. The post-teaching questionnaire evaluated exercises positively on several criteria, including provision of new information and relevance to future work. CONCLUSIONS: Structured teaching provided an effective and acceptable method of teaching the medicines management skills needed in the PRHO year. The structured approach complemented variable precourse clinical experience.     

Randomised, controlled study investigating the optimal instructor: student ratios for teaching suturing skills

INTRODUCTION: Recently, there has been a shift away from practising procedures on patients for the first time and towards bench model teaching of clinical skills to undergraduate medical students. However, guidelines for the most effective instructor : student ratio for technical skills training are unclear. This has important implications for staffing laboratory based teaching sessions. The purpose of this study was to assess the optimal ratio of teachers to learners during the teaching of a simulated wound closure. METHODS: A total of 108 undergraduate medical students participated in a 1-hour course on wound closure. They were randomised to 3 groups, each with a different instructor:student ratio (Group A: 6-12; Group B: 3-12; Group C: 1-12). Students were evaluated on a pre-test, an immediate post-test and a delayed retention test using an objective, computer-based technical skills assessment method. Collectively termed the "economy of movements", the total time taken to complete the task and the number of movements executed were the primary outcome measures. RESULTS: Improvements in the economy of movements were the same for Groups A and B and were better than in Group C (P < 0.005). DISCUSSION: The optimal instructor:student ratio was 1 instructor for 4 students. Higher ratios of instructors to students resulted in no improvements in learning, and lower ratios of instructors to students resulted in significantly less learning. These findings are in keeping with current motor learning theories.     

What do students actually do on an internal medicine clerkship? A log diary study

BACKGROUND: There are limited data on the amount of time students spend on teaching and learning while on internal medicine clerkships, and existing data suggest a wide international variation. Community-based teaching of internal medicine is now widespread; but its strengths and weaknesses compared to traditional hospital based teaching are still unclear. AIM: To determine the proportion of time students spend on different activities on an internal medicine clerkship, and to determine whether this differs in general practice and in hospital. In addition we aimed to determine students' views on the educational value and enjoyment of various activities. METHODS: Prospective completion of log diaries recording student activities. Each student was asked to complete the diary for two separate weeks of their internal medicine clerkship: one week of general practice-based teaching and one week of hospital-based teaching. RESULTS: The response rate was 68% (88/130). Students spent approximately 5.5 h per day on teaching and learning activities in both environments, with more time (50 min vs. 30 min, P = 0.007) on unsupervised interaction with patients in hospital than in general practice, and more time (53 min vs. 21 min, P < 0.001) undergoingassessment in general practice than in hospital. Standard deviations were wide, demonstrating the heterogeneous nature of the data. Students perceived supervised interaction with patients and teaching by doctors as the most educational activities in both environments, but found it even more educationally valuable and enjoyable in general practice than in hospital (mean score for educational value: 4.27 in general practice, 3.88 in hospital, P = 0.048; mean score for enjoyment 4.13 in general practice, 3.66 in hospital, P = 0.03). CONCLUSIONS: Students greatly value interactions with patients, perceiving these as both educational and enjoyable. Curriculum planners must continue to place patient-based learning at the centre of undergraduate medical education. The heterogeneity of the data suggests that individual students have very different experiences, despite apparently similar timetables.     

Effects of basic clinical skills training on objective structured clinical examination performance

OBJECTIVES: The aim of curriculum reform in medical education is to improve students' clinical and communication skills. However, there are contradicting results regarding the effectiveness of such reforms. METHODS: A study of internal medicine students was carried out using a static group design. The experimental group consisted of 77 students participating in 7 sessions of communication training, 7 sessions of skills-laboratory training and 7 sessions of bedside-teaching, each lasting 1.5 hours. The control group of 66 students from the traditional curriculum participated in equally as many sessions but was offered only bedside teaching. Students' cognitive and practical skills performance was assessed using Multiple Choice Question (MCQ) testing and an objective structured clinical examination (OSCE), delivered by examiners blind to group membership. RESULTS: The experimental group performed significantly better on the OSCE than did the control group (P < 0.01), whereas the groups did not differ on the MCQ test (P < 0.15). This indicates that specific training in communication and basic clinical skills enabled students to perform better in an OSCE, whereas its effects on knowledge did not differ from those of the traditional curriculum. CONCLUSION: Curriculum reform promoting communication and basic clinical skills are effective and lead to an improved performance in history taking and physical examination skills.     

Is it me or is it them? Factors that influence the passing of underperforming students

Context Research has found that clinical assessments do not always accurately reflect medical student performance. Barriers to failing underperformance in students have been identified in other vocational settings. Is ‘failure to fail’ an issue for medical educators in the UK, and, if so, what are its determinants? Methods We carried out a qualitative focus group study exploring the views of medical educators (general practitioners, hospital doctors and non‐clinical tutors) from two different UK medical schools. To make sense of a potential multitude of factors impacting on failure to fail, we selected the integrative model of behavioural prediction to underpin our data collection and analysis. Results Ten focus groups were carried out with 70 participants. Using both theory and data‐driven framework analysis, we identified six main themes relevant to the integrative model of behavioural prediction. These are: tutor attitudes towards an individual student; tutor attitudes towards failing a student; normative beliefs and motivation to comply; efficacy beliefs (self‐efficacy); skills and knowledge, and environmental constraints. Discussion Many different factors impact on medical educators’ failure to report underperformance in students. There are conflicts between these factors and the need to report competence accurately (i.e. duty to protect the public). Although some of the barriers identified are similar to those found in previous studies, using a theory‐based approach added value in that it facilitated a richer exploration of failure to fail. Insights offered in this study will be used to plan a questionnaire study and subsequent intervention to support medical educators in accurately reporting underperformance in students.     

What can clinical teachers learn from Harry Potter and the Philosopher's Stone?

Many clinical teachers acquire a working knowledge of the principles of teaching and learning through observation, by adopting positive and rejecting negative examples of clinical instruction. Well selected vignettes of teaching behaviours taken from contemporary film and literature may provide rich substrate by which to engage clinical teachers in discourse about instructional technique. This paper draws on J K Rowling's novel and its companion film, Harry Potter and the Philosopher's Stone, and critically analyses the teaching styles of the staff at Hogwarts School of Wizardry and Witchcraft in the context of contemporary generic and medical education literature. Specifically, it argues that effective teachers demonstrate not only an in-depth knowledge of their discipline but possess a keen appreciation of the cognitive changes that occur in their students during the learning process. They are, furthermore, proficient in core instructional skills such as small group facilitation, feedback and questioning. Most importantly, effective teachers model appropriate attitudes in their professional setting and possess highly developed personal qualities such as creativity, flexibility and enthusiasm.     

Pilot study of a ‘RIME’‐based tool for giving feedback in a multi‐specialty longitudinal clerkship

Context The Reporter–Interpreter–Manager–Educator (RIME) evaluation framework is intuitive and reliable. Our preceptors’ frustration with using summative tools for formative feedback and the hypothesis that the RIME vocabulary might improve students’ and preceptors’ experiences with feedback prompted us to develop and pilot a RIME‐based feedback tool. Methods The tool was based on the RIME vocabulary, which has previously been used for evaluation. As interpersonal skills and professionalism are difficult areas in which to give feedback, we added these as explicit categories. We piloted the tool in a longitudinal, 5‐month, multi‐specialty clerkship. Preceptors completed pre‐ and post‐introductory workshop surveys. Students completed post‐workshop and post‐clerkship surveys. Results Preceptors (n = 14) and students (n = 8) preferred RIME‐based feedback to ‘usual feedback’ (previously given using end‐of‐clerkship evaluation forms). After the initial workshop, preceptors expected that giving feedback, including critical feedback, would be easier. After the 5‐month clerkship, students reported receiving more feedback than in previous clerkships and rated feedback given using this tool more highly (P = 0.002; effect size 1.2). Students also felt it helped them understand specifically how to improve their performance (P = 0.003; effect size 1.2). Discussion In this pilot study, preceptors and students preferred feedback with a specific RIME‐based tool. Students felt such feedback was more useful and helped them identify specifically how to improve. Whether this method can improve student performance through improved feedback remains an area for further research.     

Training clinical teachers in psychiatry to teach interviewing skills to medical students

To study the feasibility of training all clinical teachers in psychiatry to teach interviewing skills to medical students, 24 (unselected clinicians were assigned to one of four different training methods. They received either experiential or didactic instruction, and their initial teaching sessions were either supervised or unsupervised. A total of 287 medical students subsequently received feedback training from these teachers. While all students showed significant increases in skill after training, those taught by experientially trained teachers showed the greatest gains. Neither supervision nor the teachers' own interviewing skills exerted significant effects on students' performance. It is concluded that with only brief training unselected clinicians can become effective teachers of essential interviewing skills. Feedback training in such skills can, therefore, be incorporated into existing curricula without major disruption of other requirements.     

How can we prepare medical students for theatre‐based learning?

CONTEXT: The quality of medical undergraduate operating theatre-based teaching is variable. Preparation prior to attending theatre may support student learning. Identifying and agreeing key skills, competences and objectives for theatre-based teaching may contribute to this process of preparation. METHODS: We carried out a cross-sectional survey of consultant surgeons and students using a forced choice questionnaire containing 16 skills and competences classified as 'essential', 'desirable' or 'not appropriate', and a choice of 6 different teaching methods, scored for perceived effectiveness on a 5-point Likert scale. Questionnaire content was based on the findings from an earlier qualitative study. RESULTS: Comparative data analyses (Mann- Whitney and Kruskal-Wallis tests) were carried out using SPSS Version 14. A total of 42 consultant surgeons and 46 students completed the questionnaire (46% and 100% response rates, respectively). Knowledge of standard theatre etiquette and protocols, ability to scrub up adequately, ability to adhere to sterile procedures, awareness of risks to self, staff and patients, and appreciation of the need for careful peri-operative monitoring were considered 'essential' by the majority. Student and consultant responses differed significantly on 5 items, with students generally considering more practical skills and competences to be essential. Differences between students on medical and surgical attachments were also identified. CONCLUSIONS: Consultant surgeons and medical students agree on many aspects of the important learning points for theatre-based teaching. Compared with their teachers, students, particularly those on attachment to surgical specialties, are more ambitious - perhaps overly so - in the level of practical skills and risk awareness they expect to gain in theatre.     

The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students

INTRODUCTION: Much of undergraduate clinical teaching is provided by residents. An earlier study showed the attitude of residents towards teaching to be generally positive. Little is known, however, about attending doctors' views on their own and residents' roles as teachers of medical students. OBJECTIVES: To examine attending doctors' perceptions of the (dis)advantages of resident teaching, their own teaching abilities and the need for a teacher training programme for residents. METHOD: A questionnaire survey of 76 attending doctors was carried out in the Departments of Obstetrics & Gynaecology and Paediatrics at the teaching hospitals of the Universities of Maastricht and Amsterdam, the Netherlands. RESULTS: Attending doctors perceive teaching by residents to be beneficial for students and residents alike. Although they consider themselves to be better suited than residents to teach medical students, they see teaching as an integral part of residency training and feel it should be recognised as such by departments and medical schools. Attending doctors are in favour of a teacher training programme for residents, which should include communication, clinical and teaching skills as well as skills such as time management and (self-) assessment. DISCUSSION: Despite the uneven distribution of participants between the departments, no significant differences were found between departments. It is interesting that attending doctors perceive teacher training as beneficial to residents' teaching skills, but provide more feedback on residents' attitudes than on their teaching. The results show that, in general, attending doctors share residents' views that teaching is an important component of residency and that a teacher training programme for residents is to be recommended.     

Medical teachers' concerns about the clinical teaching context

INTRODUCTION: Despite several unique aspects of the medical teacher's role compared to other teachers in higher education, there has been little research in this area. In particular there have been few studies which have explored teachers' perspectives on their role. This study aimed to elicit teachers' perceptions of the teaching environment in a single medical school at a time of curriculum change. METHODS: As part of an ethnographic study to explore the culture of the school, 22 teachers took part in in-depth, semi-structured interviews to ascertain their views and experiences of teaching. Additional data were collected through participant observation of curriculum meetings, and informal data collection. The data were analysed using a grounded approach, which resulted in over 200 analytic codes being assigned, which were later grouped into six main themes. RESULTS: The strongest themes to emerge were teachers' concerns about the students, the infrastructure for teaching and their relationship with the medical school. These included concerns about the lack of student clerking activity, insufficient monitoring of students, poor support or recognition of teaching and a perceived lack of inclusion in the medical school. DISCUSSION: The structure and culture within the medical school and associated hospital trust appeared to offer little support for doctors in their teaching role. This suggested that teaching was not highly valued. Teachers were preoccupied with the practical issues of teaching, leaving little time to consider more fundamental educational issues. These findings have implications for the quality of teaching and implementation of curricular change.     

Medical student interviewing skills and mother-reported satisfaction and recall

BACKGROUND: Providing feedback to medical students about their interviewing skills is an important component of teaching programmes. There is very little information about mothers' views of medical student consultations in paediatrics, and in particular about what mothers consider to be the key elements of a successful consultation. Patient-centred interviewing is a model which emphasizes the active seeking of patient views. In association with appropriate clinical skills, it is reported to promote improved health outcomes. OBJECTIVES: To examine whether greater medical student clinical competence and more frequent use of patient-centred techniques is associated with higher maternal satisfaction, higher maternal rating of the medical student's interpersonal skills, and greater maternal recall of relevant diagnosis and treatment recommendations. METHOD: Two standardized 'medical student' videotaped interviews were created based on actual senior medical student consultations. Interview A demonstrated both higher student clinical competence and higher patient-centredness compared with interview B. Both videotaped interviews were viewed and then rated, using a questionnaire, by 11 mothers attending a teaching general practice. RESULTS: Significantly higher mean scores, indicating greater maternal satisfaction, were associated with interview A (P < 0.01 for all measures). Accurate recall for diagnosis and management was also significantly greater after interview A (mean diagnosis recall, interview A 35%, interview B 14%, P < 0.01; mean management recall, interview A 95%, interview B 57%, P < 0.01). CONCLUSIONS: Maternal satisfaction and recall were higher following a more clinically competent and patient-centred medical student interview. Maternal ratings of student interviews could be used as an additional method of assessment as well as providing feedback to medical students on their interview skills development.     

Does ultrasound training boost Year 1 medical student competence and confidence when learning abdominal examination?

OBJECTIVES: Learning to perform physical examination of the abdomen is a challenge for medical students. Medical educators need to find engaging, effective tools to help students acquire competence and confidence in abdominal examination techniques. This study evaluates the added value of ultrasound training when Year 1 medical students learn abdominal examination. METHODS: The study used a randomised trial with a wait-list control condition. Year 1 medical students were randomised into 2 groups: those who were given immediate ultrasound training, and those for whom ultrasound training was delayed while they received standard instruction on abdominal examination. Standardised patients (SPs) used a clinical skills assessment (CSA) checklist to assess student abdominal examination competence on 2 occasions - CSA-1 and CSA-2 - separated by 8 weeks. Students also estimated SP liver size for comparison with gold-standard ultrasound measurements. Students completed skills confidence surveys. RESULTS: Proficiency in abdominal examination technique acquired from traditional instruction boosted with ultrasound training showed no advantage at CSA-1. However, at CSA-2 the delayed ultrasound training group showed significant improvement. Students uniformly underestimated SP liver sizes and the estimates were not affected by ultrasound training. Student confidence in both groups improved from baseline to CSA-1 and CSA-2. CONCLUSIONS: Ultrasound training as an adjunct to traditional means of teaching abdominal examination improves students' physical examination technique after students have acquired skills with basic examination manoeuvres.     

Evaluation of procedural skills training in an undergraduate curriculum

CONTEXT: A substantial proportion of medical students enter their intern year without any basic skills experience. Lack of experience is a significant source of stress for many junior doctors. OBJECTIVES: To evaluate the effect of a basic procedural skills tutorial for Year 3 medical students on their competence in relevant skills at Year 5. SUBJECTS: The control group consisted of 93 medical students who completed Year 3 in 1996. The intervention group consisted of 92 medical students who completed Year 3 in 1997. The intervention group received a practical skills tutorial in Year 3; the control group did not. Both groups were assessed on their practical skills competence during Year 5. METHODS: A 3-hour practical tutorial on injection and suturing techniques was delivered to the intervention group. The effectiveness of the intervention was assessed by self-reported experience of giving injections, inserting sutures and sustaining needlestick injuries, and by teacher-rated competency in four basic procedural skills. RESULTS: Students who received the Year 3 tutorial were significantly more likely to record a satisfactory assessment for their performance in all four basic skills compared with students who did not receive the tutorial. They were less likely than controls to refuse invitations to give injections, but not invitations to insert a suture, during Years 4 and 5. CONCLUSIONS: A single session of formalised teaching in procedural skills in the early stages of a medical degree can have long-term effectiveness in basic skills competence and may increase students' confidence to practise their skills.     

Patients' global ratings of student competence. Unreliable contamination or gold standard?

Purpose To determine whether global ratings by patients are valid and reliable enough to be used within a major summative assessment of medical students' clinical skills. Method In 11 stations of an 18‐station objective structured clinical examination (OSCE), where a student was asked to educate or take a history from a patient, the patient was asked, ‘How likely would you be to come back and discuss your concerns with this student again?’ These 11 opinions were aggregated into a single patient opinion mark and correlated with other measures of student competence. The patients were not experienced in student assessment. Results A total of 204 students undertook the OSCE. Reliability of patient opinion across all 11 stations revealed a Cronbach alpha of 0·65. The correlation coefficient between the patient ratings and the total OSCE score was good (r = 0·74; P < 0·001) and was better than the correlation between any single OSCE station and the total OSCE score. It was also better than the correlation between the aggregated patient opinion and tests of student knowledge (r = 0·47). Conclusion It is known that patients can reliably complete checklists of clinical skills and that doctors can reliably provide global ratings of students. We have now shown that, by controlling the context, asking the right question and aggregating several opinions, untrained patients can provide a reliable and valid global opinion that contributes to the assessment of a student's clinical skills.