Testing an empirically derived mental health training model featuring small groups, distributed practice and patient discussion

Objectives  Internationally, family doctors seeking to enhance their skills in evidence-based mental health treatment are attending brief training workshops, despite clear evidence in the literature that short-term, massed formats are not likely to improve skills in this complex area. Reviews of the educational literature suggest that an optimal model of training would incorporate distributed practice techniques; repeated practice over a lengthy time period, small-group interactive learning, mentoring relationships, skills-based training and an ongoing discussion of actual patients. This study investigates the potential role of group-based training incorporating multiple aspects of good pedagogy for training doctors in basic competencies in brief cognitive behaviour therapy (BCBT).
Methods  Six groups of family doctors ( n  = 32) completed eight 2-hour sessions of BCBT group training over a 6-month period. A baseline control design was utilised with pre- and post-training measures of doctors' BCBT skills, knowledge and engagement in BCBT treatment.
Results  Family doctors' knowledge, skills in and actual use of BCBT with patients improved significantly over the course of training compared with the control period.
Conclusions  This research demonstrates preliminary support for the efficacy of an empirically derived group training model for family doctors. Brief CBT group-based training could prove to be an effective and viable model for future doctor training.     

Evaluation of a surgical simulator for learning clinical anatomy

BACKGROUND: New techniques in imaging and surgery have made 3-dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self-study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting. METHODS: Two groups of medical students studied shoulder joint anatomy using either a second-generation virtual reality surgical simulator or images from a textbook. They were then asked to identify anatomical structures of the shoulder joint as they appeared in a videotape of a live arthroscopic procedure. RESULTS: The mean identification scores, out of a possible score of 7, were 3.1 +/- 1.3 for the simulator group and 2.9 +/- 1.5 for the textbook group (P = 0.70). Student ratings of the 2 methods on a 5-point Likert scale were significantly different. The simulator group rated the simulator more highly as an effective learning tool than the textbook group rated the textbook (means of 3.2 +/- 0.7 and 2.6 +/- 0.5, respectively, P = 0.02). Furthermore, the simulator group indicated that they were more likely to use the simulator as a learning tool if it were available to them than the textbook group was willing to use the textbook (means of 4.0 +/- 1.2 and 3.0 +/- 0.9, respectively, P = 0.02). CONCLUSION: Our results show that this surgical simulator is at least as effective as textbook images for learning anatomy and could enhance student learning through increased motivation. These findings provide insight into simulator development and strategies for learning anatomy. Possible explanations and future research directions are discussed.     

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

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

Developing professional clinical skills for practice – the results of a feasibility study using a reflective approach to intimate examination

Objectives  To develop a student-selected component (SSC) for junior medical students, to evaluate the feasibility of incorporating the development of skills in carrying out an intimate examination, whilst developing professional thinking skills using a reflective approach.
Subjects  The student selected component was designed for a maximum of 6 students over a 4-week period in Phase 2 (year 2 and 3) of the undergraduate medical curriculum.
Setting  The Clinical Skills Centre, the Faculty of Medicine Nursing and Dentistry, University of Dundee, Scotland, UK.
Methods  The SSC consisted of a weekly patient clerking from the ward, an analysis of the clinical and communication skills for any intimate examinations the patient would require, and practice using simulators and simulated patients. Students were supported by timed periods of structured reflection, which enabled them to discuss ethical issues and their own professional conduct related to carrying out an intimate examination. The SSC was evaluated on 3 levels; student satisfaction, learning professional thinking using a reflective approach, and observing behaviour change in relation to skill development, using a ward simulation exercise.
Results  The evaluation at the levels of student satisfaction, learning professional thinking and changes in behaviour associated with intimate examination demonstrated that the SSC had been well received by the students, who felt they had improved their skills in intimate examinations in the context of a ward simulation exercise, in parallel with their professional thinking skills.
Conclusion  It is possible to develop the professional thinking of junior medical students at the same time as developing their technical competence in relation to intimate examinations. It may be advantageous to introduce students early to this reflective approach, using simulation to promote the integration of theory with practice.     

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

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

Validity of the visual analogue scale as an instrument to measure self-efficacy in resuscitation skills

Context  Self-efficacy is an important factor in many areas of medical education, including self-assessment and self-directed learning, but has been little studied in resuscitation training, possibly because of the lack of a simple measurement instrument.
Objective  We aimed to assess the validity of a visual analogue scale (VAS) linked to a single question as an instrument to measure self-efficacy with respect to resuscitation skills by comparing the VAS with a questionnaire and using known-groups comparisons.
Methods  We developed questionnaires to measure self-efficacy for a number of resuscitation tasks and for computer skills. These were compared with VASs linked to a single question per task, using a multi-trait, multi-method matrix. We also used known-groups comparisons of self-efficacy in specific professional groups.
Results  There was good correlation between the questionnaires and the VASs for self-efficacy for specific resuscitation tasks. There was a less clear correlation for self-efficacy for paediatric resuscitation overall. There was no correlation between self-efficacy for resuscitation and computer tasks. In specific professional groups, measured self-efficacy accorded with theoretical predictions.
Conclusions  A VAS linked to a single question appears to be a valid method of measuring self-efficacy with respect to specific well defined resuscitation tasks, but should be used with caution for multi-faceted tasks.     

Optimal sequencing of bedside teaching and computer-based learning: a randomised trial

Objectives  We aimed to establish the most effective order in which to deliver teaching to medical students when using both bedside teaching (BT) and computer-based learning (CBL) and to ascertain the students' preferred method and order of delivery.
Methods  A sample of 28 medical students were randomly divided into two equal groups during their orthopaedic knee examination teaching session. Group 1 received standard BT and group 2 undertook a CBL package. Each group then undertook an objective structured clinical examination (OSCE). The groups then received the other method of teaching followed by another OSCE. A questionnaire was administered to all students to assess their views on, and preferences for, the various teaching methods.
Results  Mean scores on the first OSCE were 12.19 for group 1 (BT then CBL) and 11.96 for group 2 (CBL then BT) ( P  = 0.692). Mean scores on the second OSCE were 11.81 for group 1 compared with 12.79 for group 2 ( P  = 0.038). Statistical analysis showed a significantly better score improvement for group 2 (CBL then BT) over group 1 (BT then CBL). Of the 26 students who returned questionnaires, 24 (92%) expressed their preference for traditional BT over CBL only, and 23 (88%) were in favour of undertaking CBL prior to traditional BT.
Conclusions  The CBL package is a useful tool and is most effective if used before BT. Students prefer BT alone over CBL alone, but, if offered both, prefer to undertake CBL first.     

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

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

Learning the skills of flexible sigmoidoscopy – the wider perspective

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

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.     

The effect of testing on skills learning

Objectives  In addition to the extrinsic effects of assessment and examinations on students' study habits, testing can have an intrinsic effect on the memory of studied material. Whether this testing effect also applies to skills learning is not known. However, this is especially interesting in view of the need to maximise learning outcomes from costly simulation-based courses. This study was conducted to determine whether testing as the final activity in a skills course increases learning outcome compared with an equal amount of time spent practising the skill.
Methods  We carried out a prospective, controlled, randomised, single-blind, post-test-only intervention study, preceded by a similar pre- and post-test pilot study in order to make a power calculation. A total of 140 medical students participating in a mandatory 4-hour in-hospital resuscitation course in the seventh semester were randomised to either the intervention or control group and were invited to participate in an assessment of learning outcome. The intervention course included 3.5 hours of instruction and training followed by 30 minutes of testing. The control course included 4 hours of instruction and training. Participant learning outcomes were assessed 2 weeks after the course in a simulated scenario using a checklist. Total assessment scores were compared between the two groups.
Results  Overall, 81 of the 140 students volunteered to participate. Learning outcomes were significantly higher in the intervention group ( n  = 41; mean score 82.8%, 95% confidence interval [CI] 79.4–86.2) compared with the control group ( n  = 40; mean score 73.3%, 95% CI 70.5–76.1) ( P  < 0.001). Effect size was 0.93.
Conclusions  Testing as a final activity in a resuscitation skills course for medical students increases learning outcome compared with spending an equal amount of time practising the skills.     

The impact of case specificity and generalisable skills on clinical performance: a correlated traits-correlated methods approach

Context  The finding of case or content specificity in medical problem solving moved the focus of research away from generalisable skills towards the importance of content knowledge. However, controversy about the content dependency of clinical performance and the generalisability of skills remains.
Objectives  This study aimed to explore the relative impact of both perspectives (case specificity and generalisable skills) on different components (history taking, physical examination, communication) of clinical performance within and across cases.
Methods  Data from a clinical performance examination (CPX) taken by 350 Year 3 students were used in a correlated traits−correlated methods (CTCM) approach using confirmatory factor analysis, whereby 'traits' refers to generalisable skills and 'methods' to individual cases. The baseline CTCM model was analysed and compared with four nested models using structural equation modelling techniques. The CPX consisted of three skills components and five cases.
Results  Comparison of the four different models with the least-restricted baseline CTCM model revealed that a model with uncorrelated generalisable skills factors and correlated case-specific knowledge factors represented the data best. The generalisable processes found in history taking, physical examination and communication were responsible for half the explained variance, in comparison with the variance related to case specificity.
Conclusions  Pure knowledge-based and pure skill-based perspectives on clinical performance both seem too one-dimensional and new evidence supports the idea that a substantial amount of variance contributes to both aspects of performance. It could be concluded that generalisable skills and specialised knowledge go hand in hand: both are essential aspects of clinical performance.     

Trialling a new way to learn clinical skills: systematic clinical appraisal and learning

AIM: To describe and evaluate the effectiveness of a new method of teaching clinical skills designed to increase students' active and self-directed learning as well as tutor feedback. METHODS: A total of 22 consenting Year 4 medical students undertaking general practice and general surgery clinical experience were involved in a pre- and post-test research design. In the initial period of the study, students were taught clinical skills in a traditional manner. In the second phase a clinical teaching strategy called systematic clinical appraisal and learning (SCAL) was utilised. This learning strategy involved active and self-directed learning, holistic care and immediate feedback. Students independently saw a patient and were asked to make judgements about the patient's potential diagnosis, tests required, management, psychosocial needs, preventive health requirements, and any ethical problems. These judgements were then compared with those of the clinical supervisor, who saw the same patient independently. Students recorded details for each consultation. Comparisons were made of the two study periods to examine whether the use of SCAL increased the number of students' independent judgements, perceived student learning, tutor feedback and self-directed learning. RESULTS: During the SCAL learning period, students reported making a greater number of statistically significant independent judgements, and receiving significantly increased tutor feedback in both general practice and general surgery. The number of learning goals set by students was not found to differ between the two periods in surgery but significantly increased in general practice in the SCAL period. Students' perceptions of their learning significantly increased in the SCAL period in surgery but not in general practice. During the traditional learning period in both settings, there was limited student decision-making about most aspects of care, but particularly those relating to prevention, psychosocial issues and ethics. CONCLUSIONS: The SCAL approach appears to offer some advantages over traditional clinical skills teaching. It appears to encourage active and independent decision-making, and to increase tutor feedback. Further exploration of the approach appears warranted.     

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.     

Student perceptions of a portfolio assessment process

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

Content specificity: is it the full story? Statistical modelling of a clinical skills examination

Objective  This study sought to determine the relative contributions made by transferable skills and content-specific skills to Year 2 medical student performance in a clinical skills examination.
Methods  Correlated trait-correlated method models were constructed to describe the performance of 2 year groups of students in examinations held in the summers of 2004 and 2005 at Peninsula Medical School in the UK. The transferable skills components of the models were then removed to indicate the contribution made to the fit of the models to the data.
Results  Although content-specific skills made the greater contribution to the 2 models of student performance (accounting for averages of 54% and 43% of the variance, respectively), transferable skills did make an important but smaller contribution (averages of 13% and 16%, respectively). When the transferable skills components of the models were removed, the fit was not as good.
Conclusions  Both content-specific skills and transferable skills contributed to performance in the clinical skills examination. This challenges current thinking and has important implications, not just for those involved in clinical skills examinations, but for all medical educators.     

Setting up a clinical skills learning facility

Objective  This paper outlines the considerations to be made when establishing a clinical skills learning facility.
Considerations  Establishing a clinical skills learning facility is a complex project with many possible options to be considered. A number of professional groups, undergraduate or postgraduate, may be users. Their collaboration can have benefits for funding, uses and promotion of interprofessional education. Best evidence and educational theory should underpin teaching and learning. The physical environment should be flexible to allow a range of clinical settings to be simulated and to facilitate a range of teaching and learning methods, supported by computing and audio-visual resources. Facilities should be available to encourage self-directed learning. The skills programme should be designed to support the intended learning outcomes and be integrated within the overall curriculum, including within the assessment strategy. Teaching staff may be configured in a number of ways and may be drawn from a variety of backgrounds. Appropriate staff development will be required to ensure consistency and quality of teaching with monitoring and evaluation to assure appropriate standards. Patients can also play a role, not only as passive teaching material, but also as teachers and assessors. Clinical, diagnostic and therapeutic equipment will be required, as will models and manikins. The latter will vary from simple part task trainers to highly sophisticated human patient simulators. Care must be taken when choosing equipment to ensure it matches specified requirements for teaching and learning.
Conclusion  Detailed planning is required across a number of domains when setting up a clinical skills learning facility.     

Fostering diagnostic knowledge through computer-supported, case-based worked examples: effects of erroneous examples and feedback

Objectives  A case-based, worked example approach was realised in a computer-based learning environment with the intention of facilitating medical students' diagnostic knowledge. In order to enhance the effectiveness of the approach, two additional measures were implemented: erroneous examples and elaborated feedback. In the context of an experimental study, the two measures were varied experimentally.
Methods  A total of 153 medical students were randomly assigned to four experimental conditions of a 2 × 2-factor design (errors versus no errors, elaborated feedback versus knowledge of correct result [KCR]). In order to verify the sustainability of the effects, a subgroup of subjects ( n  = 52) was compared with a control group of students who did not participate in the experiment ( n  = 145) on a regular multiple-choice question (MCQ) test.
Results  Results show that the acquisition of diagnostic knowledge is mainly supported by providing erroneous examples in combination with elaborated feedback. These effects were independent from differences in time-on-task and prior knowledge. Furthermore, the effects of the learning environment proved sustainable.
Conclusions  Our results demonstrate that the case-based, worked example approach is effective and efficient.     

Developing a Korean communication skills attitude scale: comparing attitudes between Korea and the West

Objectives  We aimed to develop a Korean version of the Communication Skills Attitude Scale (CSAS) created by Rees et al . in order to elucidate the positive and negative aspects of Korean pre-medical and medical students' attitudes towards communication skills (CS) learning.
Methods  We performed two surveys. In the first of these, 325 pre-medical and medical students completed a translated version of the CSAS. In the second survey, 257 medical students and doctors-in-training answered five open-ended questions to obtain more qualitative data about their attitudes.
Results  Principal component analysis with direct oblimin rotation performed with the data from the first survey produced the following five factors: facilitation of interpersonal skills; doubts about the importance of CS learning in medicine; motivation; negative attitudes towards assessment, and overconfidence. Results from the second survey indicated that facilitation and importance within a medical context were two core attitudinal factors and suggested some modification to the CSAS to improve its fit for Korean pre-medical and medical students.
Conclusions  Using a Korean version of the CSAS (CSAS-K), we determined five factors that revealed a somewhat complex attitude structure among students towards CS learning. The CSAS required some modification, possibly because CS teaching and learning in Korea are in the development stage. Finally, the educational implications of the results are discussed.     

Pre-registration house officers and ward-based learning: a 'new apprenticeship' model

INTRODUCTION: The pre-registration house officer (PRHO) year can be seen as a formal apprenticeship into the profession of medicine, and as central to the identity construction of the doctor. The year characteristically involves rotation between specialties, including attachment to ward-based 'firms', where consultants teach PRHOs. DISCUSSION: Teaching and learning in ward-based environments is under-researched, and the current literature displays a bias towards a psychological model of pedagogy that focuses upon transmission of knowledge and skills from one individual to another. Such a model offers a necessary, but not sufficient, explanation of how work-based learning occurs. Understanding the PRHO apprenticeship year should include reference to cultural dimensions to learning, especially socialisation into the profession. This constitutes an 'extended' (or 'hidden') curriculum model that may be theorised through contemporary ideas of activity learning within a 'new apprenticeship' framework. CONCLUSION: The dominant psychological model can lead to an expectation for a uniform method of teaching and learning in ward round contexts that (a) ignores important differences in educational climate between established communities of practice, and (b) orients both teachers and learners to one-to-one transmission and reception, rather than sensitising to how knowledge may be held across members of a working group. The latter shifts emphasis away from reception to issues of active access. PRHOs, as novices, are not relegated to passive learning roles, but may actively co-construct knowledge with experts, offering potential transformation of the practices of ward groups.