Towards effective outcomes in teaching, learning and assessment of law in medical education

Medical Education 2011: 45 : 339–346 Context Law is slowly emerging as a core subject area in medical education, alongside content on the ethical responsibilities of doctors to protect and promote patient health and well‐being. Curriculum statements have begun to advise on core content and methods for organising teaching and assessment. However, no comprehensive overview of approaches to the delivery of this law curriculum has been undertaken. Objectives This paper reports an assessment of the nature and strength of the published evidence base for the teaching, learning and assessment of law in medical education. It also provides a thematic content overview from the best available literature on the teaching of law to medical students and on the assessment of their legal knowledge and skills. Methods A systematic review of the evidence base was completed. Detailed scrutiny resulted in the inclusion of 31 empirical sources and 11 conceptual papers. The quality of the included material was assessed. Results Significant gaps exist in the evidence base. Empirical studies of the teaching of law are characterised by insufficient sample sizes and a focus on individual study programmes. They rely on measures of student satisfaction and on evaluating short‐term outcomes rather than assessing whether knowledge is retained and whether learning impacts on patient outcomes. Studies reveal a lack of coordination between pre‐ or non‐clinical and clinical medico‐legal education. Although evidence on the development of students’ knowledge is available, much learning is distant from the practice in which its application would be tested. Law learning in clinical placements appears to be opportunistic rather than structured. Conclusions The place of law in the curriculum remains uncertain and should be more clearly identified. A more robust knowledge base is needed to realise the aspirations behind curriculum statements on law and to enable medical students to develop sufficient legal literacy to manage challenging practice encounters. Further research is needed into effective methods of teaching, learning and assessing legal knowledge and skills during and following initial medical education.     

The accountability of clinical education: its definition and assessment

BACKGROUND: Medical education is not exempt from increasing societal expectations of accountability. Competition for financial resources requires medical educators to demonstrate cost-effective educational practice; health care practitioners, the products of medical education programmes, must meet increasing standards of professionalism; the culture of evidence-based medicine demands an evaluation of the effect educational programmes have on health care and service delivery. Educators cannot demonstrate that graduates possess the required attributes, or that their programmes have the desired impact on health care without appropriate assessment tools and measures of outcome. OBJECTIVE: To determine to what extent currently available assessment approaches can measure potentially relevant medical education outcomes addressing practitioner performance, health care delivery and population health, in order to highlight areas in need of research and development. METHODS: Illustrative publications about desirable professional behaviour were synthesized to obtain examples of required competencies and health outcomes. A MEDLINE search for available assessment tools and measures of health outcome was performed. RESULTS: There are extensive tools for assessing clinical skills and knowledge. Some work has been done on the use of professional judgement for assessing professional behaviours; scholarship; and multiprofessional team working; but much more is needed. Very little literature exists on assessing group attributes of professionals, such as clinical governance, evidence-based practice and workforce allocation, and even less on examining individual patient or population health indices. CONCLUSIONS: The challenge facing medical educators is to develop new tools, many of which will rely on professional judgement, for assessing these broader competencies and outcomes.     

INTERDISCIPLINARY LEARNING IN THE REHABILITATION HOSPITAL

A project designed to teach effective collaboration to professional students in patient-centered health care included as one evaluative measure retrospective interviews with patients, preceptors, and students. This paper analyzes those responses that have implications for social work, reports on the rehabilitation hospital as a social setting, and identifies factors that enhanced or interfered with learning. Interviews highlighted student and preceptor roles as clearly reciprocal and the importance of students bringing to collaborative practice a sense of their own professional identity, skills, and knowledge base as resources to be pooled in team activity.     

Setting performance standards for medical practice: a theoretical framework

BACKGROUND: The assessment of performance in the real world of medical practice is now widely accepted as the goal of assessment at the postgraduate level. This is largely a validity issue, as it is recognised that tests of knowledge and in clinical simulations cannot on their own really measure how medical practitioners function in the broader health care system. However, the development of standards for performance-based assessment is not as well understood as in competency assessment, where simulations can more readily reflect narrower issues of knowledge and skills. This paper proposes a theoretical framework for the development of standards that reflect the more complex world in which experienced medical practitioners work. METHODS: The paper reflects the combined experiences of a group of education researchers and the results of literature searches that included identifying current health system data sources that might contribute information to the measurement of standards. CONCLUSION: Standards that reflect the complexity of medical practice may best be developed through an "expert systems" analysis of clinical conditions for which desired health care outcomes reflect the contribution of several health professionals within a complex, three-dimensional, contextual model. Examples of the model are provided, but further work is needed to test validity and measurability.     

A theoretical framework for human and veterinary medical ethics education

In their practice, physicians and veterinarians need to resort to an array of ethical competences. As a teaching topic, however, there is no accepted gold standard for human medical ethics, and veterinary medical ethics is not yet well established. This paper provides a reflection on the underlying aims of human and veterinary medical ethics education. Drawing from published literature on ethics education in the health professions a theoretical framework common to the teaching of human and veterinary medical ethics is proposed, based on three concepts: professional rules, moral virtues and ethical skills. The rules approach relies on the transmission of professional and social values by means of regulatory documents and depends intimately on the knowledge that students have of those documents. The virtues approach involves the inculcation of moral values and virtues that will stimulate students to develop desirable behaviours. The main focus of this approach to ethics is to develop students’ attitudinal competences. Finally, the skills approach is focused on equipping the students with the necessary moral reasoning abilities to recognise and respect the plurality of ethical views that make part of contemporary society. This framework can inform future curriculum development in human and veterinary medical ethics as well as in other health care professions.     

急诊科全科医师培训的实践与探索

全科医师培训是大型综合性教学医院临床教学和医疗工作的重要组成部分,培训学习是全科医师提高专业技术水平的重要途径。急诊科是全科医师培训的重要基地,全科医师的培训对急诊科乃至急诊医学的发展都非常重要。本文旨在加强全科医师的筛选,保证生源质量;注意因材施教,突出实践能力培养;拓展培养空间,注重综合能力提高;建立考评机制,调动教学双方积极性;使用与关爱结合,提供良好的后续发展支持等方面,对于提高综合性教学医院急诊科全科医师培训质量进行了有益的探索。使急诊科全科医师临床实际操作技能、专业理论知识、临床诊疗思维和职业道德素质均有了新的提高,为其今后的终生教育和发展成为一名合格的急诊科医师奠定良好基础。本文总结了急诊科全科医师培训过程中的优势和不足,并对此提出了相应的建议。     

Envisioning Quality Psychosocial Care in Nursing Homes: The Role of Social Work

This article articulates a vision of excellent psychosocial care in nursing homes using a quality assurance perspective and illustrates how skills of professional social workers can contribute to enhanced psychosocial care in this setting. Building on knowledge of actual and best practice roles for social work in nursing homes, this article serves as a call to differentiate professional social work from paraprofessional social services to support quality improvements for interprofessional psychosocial care and improved quality of life outcomes for residents.     

Towards holistic social work practice in general medical settings

This paper describes the development by field educators and social work students of a generalist model of practice related to work with general medical practitioners. The model developed outlines the values, knowledge and skills required to respond to the problems presented by intervening in a wide range of social systems. Effective social work practice is related to successful collaboration with the doctors. This is facilitated when there are close administrative links and when both groups are aware of the different perceptions on client/patient care. Conflict resolution is facilitated when the social worker encourages a focus on what is best for the client/patient and can articulate and demonstrate a practice perspective that links interaction among social, economic, political and health factors in people's lives.     

Obstacles to the practice of licensed lay midwifery

Intensive interviews with licensed lay midwives in one of ten states that have recently reactivated and revised legislation legalizing such alternative practitioners for low risk clientele revealed a number of obstacles to their practice. The obstacles stem from the same rules and regulations developed by medical practitioners that made their homebirth service legal. Even after surmounting the difficulties of obtaining a license, the midwives find widespread unwillingness among private physicians to provide the required prenatal screening examination and medical back-up. The opposition of physicians to the licensed midwifery program is voiced in terms of concern about the safety of homebirths, particularly those attended by nonphysicians. Yet, the outcomes from the first 4 years of the program give no support for such concerns. Physician reluctance to cooperate with the legal program, combined with restrictions prohibiting the licensed midwives from sulturing minor tears and administering a single dose of an antihemorrhagic drug in an emergency transfer, do compromise the overall quality of midwifery care. While accepting their subordinate position to medical practitioners, the midwives are struggling to establish the continuum of care for homebirth women implied in their licensure law.     

Improvisation as an Adaptive Strategy for Occupational Therapy Practice

ABSTRACT

As health care environments become increasingly complex, practitioners must develop new adaptive skills to master practice. The idea of using theatrical improvisation (improv) in health care is relatively new. Occupational therapy students were taught a module of improvisational techniques as part of an academic seminar, learning improvisation rules, and enacting solutions to typical daily professional challenges. The purpose of this article is to recommend improvisational techniques as an adaptive skill to effectively blend art and science for occupational therapy practice in fast-paced and unpredictable health care environments.     

Early clinical experience: do students learn what we expect?

Medical Education 2011: 45 : 731–740 Context Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged. Objectives This study describes students’ learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment. Methods A questionnaire containing open‐ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses. Results Students’ learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self‐reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes. Conclusions Students’ learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under‐represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students’ professional development are neglected in the first year of medical education.     

Longitudinal integrated rural placements: a social learning systems perspective

Objectives There is currently little theoretically informed exploration of how non‐traditional clinical placement programmes that are longitudinal, immersive, based on community‐engaged education principles and located in rural and remote settings may contribute to medical student learning. This paper aims to theoretically illustrate the pedagogical and socio‐cultural underpinnings of student learning within a longitudinal, integrated, community‐engaged rural placement. Methods Data collected using semi‐structured interviews with medical students, their supervisors and other health clinicians participating in a longitudinal rural placement programme were analysed using framework analysis. Data interpretation was informed by the theory of social learning systems (SLSs). Results In a longitudinal, rural clinical placement students participate in an SLS with distinct yet interrelated learning spaces that contain embedded communities of practice (CoPs). These spaces are characterised by varying degrees of formality, membership and interaction, and different learning opportunities and experiences. They are situated within and shaped by a unique geography of place comprising the physical and social features of the placement setting. Within these learning spaces, students acquire clinical knowledge, skills and competencies, professional attitudes, behaviours and professional values. The process of connectivity helps explain how students access and cross the boundaries between these learning spaces and develop a more complex sense of professional identity. Conclusions Longitudinal, integrated clinical placement models can be understood as SLSs comprising synergistic and complementary learning spaces, in which students engage and participate in multiple CoPs. This occurs in a context shaped by unique influences of the geography of place. This engagement provides for a range of student learning experiences, which contribute to clinical learning and the development of a more sophisticated professional identity. A range of pedagogical and practical strategies can be embedded within this SLS to enhance student learning.     

Does Practice Make Perfect?

Abstract

We tested an underlying assumption of social work field education, that more frequent practice of professional skills is associated with better student outcomes. One hundred eighty-eight students from four social work programs rated their skills and satisfaction and answered questions about frequency of practicing professional skills in field practicum. In addition, we had performance evaluations by their field instructors for 120 students. More frequent practice of nearly all 38 skills was associated with greater satisfaction with field education and greater self-evaluation of performance. Frequency of practicing about one-third of the skills was also associated with field instructors' evaluations of students. The results support the usefulness of repeatedly practicing skills in field education.     

日本和中国医师培训制度的比较研究

日本的医师培训制度具有不同于我国的特点,医学生毕业后即可参加医师资格考试,但是从事临床工作之前必须接受2年以上的临床基本知识和技能培训.日本的医师培训制度对我们有如下启示:我国应以法律条文的形式将住院医师规范化培训制度写到医师法中,而且对拟从事临床工作的医学毕业生首先实施2年的全科医学知识培训,在此基础上进行3年以上的专科医师培训,确保医师在接受培训后成为一专多能的合格医师.     

Multiprofessional learning: the attitudes of medical, nursing and pharmacy students to shared learning

OBJECTIVES: The belief that the effectiveness of patient care will improve through collaboration and teamwork within and between health care teams is providing a focus internationally for 'shared learning' in health professional education. While it may be hard to overcome structural and organizational obstacles to implementing interprofessional learning, negative student attitudes may be most difficult to change. This study has sought to quantify the attitudes of first-year medical, nursing and pharmacy students' towards interprofessional learning, at course commencement. DESIGN: The Readiness for Interprofessional Learning Scale (RIPLS) (University of Liverpool, Department of Health Care Education), was administered to first-year medical, nursing and pharmacy students at the University of Auckland. Differences between the three groups were analysed. SETTING: The Faculty of Medical and Health Sciences, University of Auckland. RESULTS: The majority of students reported positive attitudes towards shared learning. The benefits of shared learning, including the acquisition of teamworking skills, were seen to be beneficial to patient care and likely to enhance professional working relationships. However professional groups differed: nursing and pharmacy students indicated more strongly that an outcome of learning together would be more effective teamworking. Medical students were the least sure of their professional role, and considered that they required the acquisition of more knowledge and skills than nursing or pharmacy students. CONCLUSION: Developing effective teamworking skills is an appropriate focus for first-year health professional students. The timing of learning about the roles of different professionals is yet to be resolved.     

口腔科实习生岗前培训探讨

为保证口腔实习生能够顺利进入医院进行实习,最大限度地保证诊疗安全,避免医疗纠纷,在口腔实习生进行实习前,对其进行爱院爱科教育、规章制度教育、医疗安全教育、医德医风教育、组长选拔管理、实习目标制定、口腔三基培训、电脑操作培训、病历书写培训、院感知识培训、医患沟通培训、礼仪形象培训、应急能力培养等岗前培训,使口腔实习生实现从学校到医院,从课堂到病房,从学生到医生,从理论到实践的转变,减少和避免了直接进入临床后出现的问题,确保了临床实习任务的顺利完成,提高了临床实习质量。     

A mixed-methods study of interprofessional learning of resuscitation skills

Objectives This study aimed to identify the effects of interprofessional resuscitation skills teaching on medical and nursing students’ attitudes, leadership, team‐working and performance skills. Methods Year 2 medical and nursing students learned resuscitation skills in uniprofessional or interprofessional settings, prior to undergoing observational ratings of video‐recorded leadership, teamwork and skills performance and subsequent focus group interviews. The Readiness for Interprofessional Learning Scale (RIPLS) was administered pre‐ and post‐intervention and again 3–4 months later. Results There was no significant difference between interprofessional and uniprofessional teams for leadership, team dynamics or resuscitation tasks performance. Gender, previous interprofessional learning experience, professional background and previous leadership experience had no significant effect. Interview analysis showed broad support for interprofessional education (IPE) matched to clinical reality with perceived benefits for teamwork, communication and improved understanding of roles and perspectives. Concerns included inappropriate role adoption, hierarchy issues, professional identity and the timing of IPE episodes. The RIPLS subscales for professional identity and team‐working increased significantly post‐intervention for interprofessional groups but returned to pre‐test levels by 3–4 months. However, interviews showed interprofessional groups retained a ‘residual positivity’ towards IPE, more so than uniprofessional groups. Conclusions An intervention based on common, relevant, shared learning outcomes set in a realistic educational context can work with students who have differing levels of previous IPE and skills training experience. Qualitatively, positive attitudes outlast quantitative changes measured using the RIPLS. Further quantitative and qualitative work is required to examine other domains of learning, the timing of interventions and impact on attitudes towards IPE.     

Towards a model of the expert practice educator – interpreting multi-professional perspectives in the literature

The health and social care professions all rely on the use of practice placements for a substantial element of their pre-qualifying professional education, and these practice-based professions have roles for existing practitioners to oversee the education and training of students when they are on practice placements. Practice educators play a vital role in the development of new practitioners and also in the development and perpetuation of professional values and standards. In this paper, we argue that the practice educator role is thus fundamentally an ethical function, requiring moral commitment from the practice educator but also playing a critical role in maintaining the ethical values of the profession.     

Academic-Practice Partnerships in Practice Research

Summary

Academic-practice partnerships in practice research support health social workers in engaging in research that is embedded within their practice. This shift in culture enables social workers to join in a health service discourse that is increasingly data-driven and focused on effective practice and demonstrated quality of care for patients. The mentoring model is described as enabling practitioners to superimpose research skills onto existing practice skills. An academic-practice research collaboration can reduce the distance between research and practice, contribute to a body of knowledge for health social work and promote health social workers as “research focused practitioners.”