Students'' assessment of a course in obstetrics and gynaecology

A complete annual entry of 181 students were administered a questionnaire in which they were invited to make value judgements about all aspects of their 3-month course in obstetrics and gynaecology. The resulting performance indicators were used to compare individual staff and clinical firms.     

A tutor programme in obstetrics and gynaecology

A Tutor Programme was created in a third-year clerkship in obstetrics and gynaecology to remedy a student complaint of insufficient contact with teaching staff. Data obtained through the use of observational methodologies were integrated with data from questionnaires and student/teacher interviews to assess programme content, its contribution to student education, and the characteristics of student-teacher interactions. Teachers and students both expressed satisfaction at this opportunity to 'get to know each other'. A unique contribution of the programme was the discussion of a set of topics categorized as 'Medicine as a Career and Lifestyle', e.g. how to make career decisions, residency selection, etc.). These topics were not addressed elsewhere in the curriculum yet were of great importance to the students. The value of observational methods in comprehensive programme evaluation was reaffirmed.     

A conference on ethics for obstetric and gynaecological clerkship students

Integrating the teaching of medical ethics into medical students' clinical education is challenging, given the competing demands on students' time and the need for teaching to be clinically relevant. This paper describes a model programme for incorporating ethics teaching into the obstetrics and gynaecology clerkship for third-year medical students. The programme is taught by two attending teachers and a medical ethicist with experience teaching in the clinical setting of obstetrics and gynaecology. Objective pretests and posttests showed substantial improvement in students' knowledge, and student feedback has been very positive.     

The many and conflicting histories of medical education in Canada and the USA: an introduction to the paradigm wars

BACKGROUND: Medical education research is a maturing field of inquiry that derives theoretical perspectives from many domains. Yet while such theoretical diversity holds the promise of rich paradigmatic writing and debate, too often medical education researchers do not place their work in a historical or cultural context, giving the impression that they have somehow unearthed universal 'truths' about medical education. METHODS: This paper introduces some of the key 'histories' of medical education from the contexts of Anglophone Canada and the USA following a review of major works in the history of medical education. RESULTS: There are many and conflicting histories of medical education in North America that can be classified according to different socio-historical paradigms. CONCLUSIONS: To avoid the error of over-generalisation, a much greater effort must be made to include historical, sociological, economic and other social science perspectives in the design, interpretation and application of medical education research.     

Medical education change: a detailed study of six medical schools

Summary. This article reports a comparative case study of six selected USA medical schools, undertaken to identify factors that facilitate or obstruct innovation in medical education. The findings suggest that the culture of each medical school results from a combination of intra-institutional and external factors. Together these forces influence substantially the fate of educational innovations. The institutional culture influences critical elements such as educational philosophy, leadership and resources provided in support of innovation. Equally important, the culture shapes the level and type of change a school considers and implements. The findings also suggest that the availability of resources and the creative impetus present in schools giving priority to research can benefit the educational goals and facilitate educational change.     

Context in medical education: the informal ethics curriculum

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the ' informal curriculum ' that is so central to the moral development of medical students and residents.
A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a ' practical ethics of conduct ' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.     

Practical medical education in general practice

The Medical Faculty of the University of Limburg in Maastricht, The Netherlands pays special attention to extramural care. The extramural profile of the Medical Faculty also manifests itself in the curriculum. Since 1978, a 12-week clerkship in practical medical training in general practice (PMT-GP) has been offered to fifth-year students. The general aim is to acquaint students with general medical aspects as well as specific primary care aspects of health care. The programme started in the autumn of 1978 with 24 students and 24 GP teachers. At present more than 100 GP teachers, working in about 70 practices, train 120-130 students a year. The model of the PMT-GP system is characterized by six features: a ratio of one GP teacher to one student; autonomous examination by the student of at least 15 patients a week; daily follow-up discussion on the basis of patient records prepared by the student; opportunities for self-study by the student; one tutorial day a week at the Medical Faculty; intensive contacts between the Faculty and GP teachers. Key activities of the PMT-GP include autonomous contacts with patients, written records and daily follow-up discussions with the GP teacher.     

Community-based learning in obstetrics for undergraduate medical students

Summary: Medical students on their obstetrics and gynaecology attachment were randomly assigned to attend hospital ( n = 24) or general practice ( n = 18) obstetric clinics once weekly for 4 weeks. The students completed self-assessment questionnaires at the beginning and end of the attachment. There was a significant improvement in the level of knowledge and skills required for antenatal care, care in labour and postnatal care by the end of the attachment, with no difference between hospital or general practice groups. There was a significant increase in the level of interest in the future practice of obstetrics only in the general practice group. However, this difference could be explained by the greater number of students in the general practice group who were by chance in the 'no or don't know' category at the start of their attachment. We conclude that general practice based clinical teaching of obstetrics can be a suitable alternative to hospital-based clinical teaching for undergraduate medical students.     

Teaching medical students about neurosis

Practices used by medical schools in Great Britain and Ireland in the teaching of neurosis to medical students were assessed using postal questionnaires distributed to heads of departments, and to medical students at the end of their psychiatric attachments. In addition, medical students' factual knowledge about neurotic illnesses was measured using a brief multiple choice question (MCQ) test distributed with the questionnaire. There was considerable dissatisfaction among heads of departments with the way neurosis is taught, and there was general agreement that students see too many patients with psychotic illnesses and too few neurotics. Most neurotic patients are seen within departments of psychiatry and heads of department felt there was too little use of other settings such as general medical wards or general practice. Factual knowledge about neurosis as assessed by the MCQ was generally poor. Knowledge about neurotic illnesses relates most closely to the time devoted by departments to formal lectures on neurosis and is inversely related to the proportion of psychotic patients seen by students. Teaching of techniques of medical interviewing including the use of audio and video feedback of interviewing skills and behaviours is now widespread in British medical schools. There was no tendency for students receiving such teaching to display a better knowledge about neurosis.     

The effect of clerkship site on medical student examination grades

Fairness and equity in grading medical students is a subject of continuing interest and concern. It appeared that the students on one clerkship site, the emergency room, were scoring less well on the written final examination than those on the other clerkship sites. Correlating the scores confirmed this impression. A simple intervention was made, and follow-up examination of the scores revealed that it was effective; in fact, the students on the emergency clerkship are now scoring higher than those on the other sites.     

Health promotion and disease prevention: integration into a medical school curriculum

Summary: Many authorities have identified deficiencies in the education of medical students in health promotion and disease prevention. This report describes an attempt to address this problem through the longitudinal integration of health promotion and disease prevention into several major courses in the student curriculum at Harvard Medical School. We used adult learning theory to develop the curricular approach, and designed educational experiences to match the professional development of the student at different phases of medical education. Primary, secondary, and tertiary prevention were particularly germane for students in the first, second, and third years, respectively. During clerkships in the third and fourth years, especially those with a focus on ambulatory patients, students built upon earlier experiences to integrate health promotion and disease prevention into clinical practice. By unifying the teaching of disease prevention with several major required courses, we aimed to create an environment in which students could experience their learning about disease prevention in the same manner that we aspired to have them practise it: integrated throughout clinical medicine.     

The development and evaluation of a method of teaching liaison psychiatry to medical students

A method is described of teaching medical students aspects of psychiatry related to their work with physically ill patients. The teaching requires few resources and focuses on a limited number of educational objectives centred on the acquisition of knowledge of psychiatry relevant to medical practice. The course comprised eight weekly one-hour seminars held during the first clinical year attachment to medical firms, prior to the students' psychiatry attachments. Clinically based, traditional 'bedside' teaching was used, involving patients known to the students. In a preliminary analysis of the effects of the teaching, students who had participated in the seminars scored significantly better on a test of liaison psychiatry knowledge than a matched group who had not experienced the course.     

Teaching psychiatric interview skills to medical students

A teaching package is described for teaching interview skills to large blocks of medical students whilst on their psychiatric attachment. The aims of this package are to reduce students' concerns about interviewing psychiatric patients, to reinforce students' knowledge of basic interviewing skills and to introduce students to the particular skills required in taking a psychiatric history and mental state examination. The package emphasizes the following teaching methods: 'hands-on' experience of interviewing a patient in front of small groups of peers; peer feedback using check-lists which focus on three major aspects of interviewing; elicitation of facts, elicitation of feelings and control of the interview; facilitation of small-group discussions in the presence of senior psychiatrist. The active involvement of all students in interviewing psychiatric patients engages them in the learning process. Peer involvement increases motivation and was deemed by students as a supportive and constructive exercise. The presence of a senior psychiatrist ensures that discussion is focused on the process of interviewing rather than on patient pathology. Ideally this package would precede focused training throughout the subsequent psychiatric placement.     

Reliability and validity of the objective structured clinical examination in paediatrics

The assessment of clinical competence has traditionally been carried out through standard evaluations such as multiple choice question and bedside oral examinations. The attributes which constitute clinical competence are multidimensional, and we have modified the objective structured clinical examination (OSCE) to measure these various competencies. We have evaluated the validity and reliability of the OSCE in a paediatric clinical clerkship. We divided the examination into the four components of competence (clinical skills, problem-solving, knowledge, and patient management) and evaluated the performance of 77 fourth-year medical students. The skill and content domains of the OSCE were carefully defined, agreed upon, sampled and reproduced. This qualitative evaluation of the examination was both adequate and appropriate. We achieved both acceptable interstation and intertask reliability. When correlated with concurrent methods of evaluation we found the OSCE to be an accurate measure of paediatric knowledge and patient management skills. The OSCE did not correlate, however, with traditional measures of clinical skills including history-taking and physical examination. Our OSCE, as outlined, offers an objective means of identifying weaknesses and strengths in specific areas of clinical competence and is therefore an important addition to the traditional tools of evaluation.     

Assessing the mini-Clinical Evaluation Exercise in comparison to a national specialty examination

PURPOSE: To evaluate the reliability and validity of the Mini-Clinical Evaluation Exercise (mini-CEX) for postgraduate year 4 (PGY-4) internal medicine trainees compared to a high-stakes assessment of clinical competence, the Royal College of Physicians and Surgeons of Canada Comprehensive Examination in Internal Medicine (RCPSC IM examination). METHODS: Twenty-two PGY-4 residents at the University of British Columbia and the University of Calgary were evaluated, during the 6 months preceding their 2004 RCPSC IM examination, with a mean of 5.5 mini-CEX encounters (range 3-6). Experienced Royal College examiners from each site travelled to the alternate university to assess the encounters. RESULTS: The mini-CEX encounters assessed a broad range of internal medicine patient problems. The inter-encounter reliability for the residents' mean mini-CEX overall clinical competence score was 0.74. The attenuated correlation between residents' mini-CEX overall clinical competence score and their 2004 RCPSC IM oral examination score was 0.59 (P = 0.01). CONCLUSION: By examining multiple sources of validity evidence, this study suggests that the mini-CEX provides a reliable and valid assessment of clinical competence for PGY-4 trainees in internal medicine.     

Teaching disability and rehabilitation to medical students

Summary. A survey of UK medical schools was undertaken to determine the teaching that was being offered on disability and rehabilitation. In general, teaching on this topic appeared fragmented and inadequate but a number of interesting innovations were identified. These included: a drama workshop run by a group whose members mainly have learning disabilities at St George's Medical School, student-directed learning at the University of Dundee and structured teaching programmes at the Universities of Leeds and Edinburgh. The General Medical Council Education Committee's 1991 discussion document on the undergraduate curriculum specifically mentions disability as an important topic. A number of schools mentioned that they were in the process of revising their curriculum as a consequence. Recommendations arising from the findings of the survey include integration of disability and rehabilitation into clinical teaching, focus of teaching on those types of disability which are common in the community, greater emphasis on functional assessment in teaching the physical examination, and the wider use of standard assessment instruments, for example for activities of daily living, cognitive impairment and locomotor disability. There is a need for improved communication between medical schools to facilitate the spread of educational activities on this topic.     

A comparison of the performance on three multiple choice question papers in obstetrics and gynaecology over a period of three years administered at five London medical schools

Four, and later five, of the medical schools in the University of London collaborated in administering one multiple choice question (MCQ) paper in Obstetrics and Gynaecology to their students at the end of the Obstetrics and Gynaecology courses. The paper was amended twice after intervals of approximately 12 months. The results showed differences in performance between the five schools on questions and alternatives within questions, which were common to all editions of the paper (the ‘short’ paper). These differences were also shown in the first two editions of the full paper (the ‘long’ paper), but were not apparent in the third. There was a significant improvement in performance from the first to the second paper edition of the long by approximately 11%, but this was reversed from the second to the third edition, where there was a significant decrease in performance by approximately 4%. We cannot here exclude the possibility that this decrease in the third edition has resulted from sample bias. The rank order of the schools may result from differences in methods of teaching. It seems that such relative performance between London medical schools is contributed to by the differences in course length and by the occurrence of a mid-course test. It appears also that student performance in any of the schools has not been uniform over the period of the study, there being a peak during the period when the second edition of the paper was used. Variations in student selection occurring between schools may effect some of these differences. There was also a marked difference in students' performance between Obstetrics and Gynaecology. The short papers appeared easier than the full papers. Whilst this may be due to the greater clarity of phrasing for the questions of the short paper, we also believe the subject matter of the short paper may be more relevant. A distinct effect could also be shown, over the period, due to improvements in the wording of the questions. It is possible that students perform better at Obstetrics than at Gynaecology.     

Psychological tests to measure the effects of medical education on students'' interpersonal skills

The consulting skills required of medical students and practitioners have been categorized into a number of specific skills, two of which are: students' ability to empathize with the patient; and ability to decode non-verbal cues given by the patient in the interview. Training programmes to improve students' consulting skills are usually evaluated using analysis of students' actual interview behaviours with patients. Broad psychological and personality tests have also been used to measure changes in students' interviewing skills, but have generally not been successful. The hypothesis is advanced that more specific tests of the skills of interviewing, such as non-verbal sensitivity and empathy, would detect changes in students' ability to display these skills. As part evaluation of a consulting skills training programme, clinical students completed psychological tests of empathy and non-verbal sensitivity. Subsequent comparisons between trained and control student groups revealed no clear pattern in test results. These data suggest that specific psychological tests of empathy and non-verbal sensitivity may be no more effective in detecting changes in students' interpersonal skills than global personality measures.     

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.