Improving learning of a clinical skill: the first year's experience of teaching endotracheal intubation in a clinical simulation facility

BACKGROUND: All medical practitioners should be able to manage the airway of an unconscious patient. Endotracheal intubation is the most effective method of securing the airway but is a complex skill requiring much practice. Traditionally, endotracheal intubation has been taught on patients, but this is not ideal. METHODS: We have developed a short course on endotracheal intubation taught in a clinical simulation unit (CSU). This unit has a large range of airway trainers and patient simulators, some of which can be manipulated to make intubation more difficult. Endotracheal intubation is taught in a series of steps in order to avoid cognitive overload. Each step is taught on an airway trainer that has no difficult features. Once this is mastered, more difficult situations are presented which require application of new techniques and/or equipment. In this way, students learn useful schemas to apply clinically. RESULTS: In 1 year, over 100 students and trainees were taught endotracheal intubation in the CSU. The ideal group size was found to be two students and one trainer. It took 75 to 90 minutes for most students to reach a standard where they could be expected to safely perform the technique on a patient. All comments on learning endotracheal intubation in this setting were positive. Many students felt more comfortable learning on a model than on a patient. CONCLUSION: Learning clinical procedures on simulators is becoming an essential part of medical education. More than one airway trainer may be needed to give students the expertise to perform endotracheal intubation on patients.     

Student learning experiences in a longitudinal clerkship programme

Objective  To identify how medical student learning experiences in a new longitudinally integrated clinical clerkship (LICC) programme impacted students' learning.
Methods  We conducted semi-structured interviews with 12 medical students at three points in their training. We used an inductive, thematic analytic approach to data. Interviews ( n  = 35) were iteratively and independently coded by research team members to identify and corroborate key emergent themes.
Results  Students in the LICC programme reported slow but ongoing increases in patient responsibility, examination-driven learning, programme flexibility to address educational gaps, and a strong and positive perception of educational continuity through a longitudinal primary care educator and similar case mix throughout the year.
Conclusions  Student learning experiences in an LICC programme are both similar to and different from those in a traditional rotational clerkship programme. Students in the integrated clerkship were clear and unequivocal about the benefits of working with one teacher across time and caring for patients at different stages of the same disease in multiple settings. These findings have implications for clinical education development and design.     

Time spent on clerkship activities by students in relation to their perceptions of learning environment quality

Context  Students' perceptions of their learning environment are of great importance to their learning process. In this study we assessed the time allocated by students to clerkship activities and the relationship between students' allocations of time and their perceptions of the quality of their clinical learning environment.
Methods  Participants were 133 undergraduate students from eight hospitals taking part in four clerkship rotations. All students recorded the time they spent on eight clerkship activities over 2 weeks and completed the Postgraduate Hospital Educational Environment Measure (PHEEM). Partial correlation analyses were undertaken to examine the relationship between the amount of time students spent on each activity and their PHEEM scores.
Results  Students spent nearly 8 hours a day on clerkship activities. Most time was spent on observing doctors (40%), followed by participating in consultations without direct supervision (12%). The time students spent on observing doctors ( r  = 0.206, P  < 0.05) and in consultations without direct supervision ( r  = 0.211, P  < 0.05) was significantly related to the students' PHEEM scores. There was a significant relationship at the P  < 0.10 level between the time spent on directly supervised activities and students' PHEEM scores ( r  = 0.165, P  < 0.10).
Conclusions  The results suggest that the time spent on activities involving direct patient contact is positively related to students' perceptions of the quality of their learning environment. None of the activities were significantly negatively related to the students' perceptions of their clinical learning environment. Future research should examine the optimal time allocations required to enhance the perceived quality of the clinical learning environment.     

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 learning environment and medical student burnout: a multicentre study

Objectives  Little is known about specific personal and professional factors influencing student distress. The authors conducted a comprehensive assessment of how learning environment, clinical rotation factors, workload, demographics and personal life events relate to student burnout.
Methods  All medical students ( n  = 3080) at five medical schools were surveyed in the spring of 2006 using a validated instrument to assess burnout. Students were also asked about the aforementioned factors.
Results  A total of 1701 medical students (response rate 55%) completed the survey. Learning climate factors were associated with student burnout on univariate analysis (odds ratio [OR] 1.36–2.07; all P  ≤ 0.02). Being on a hospital ward rotation or a rotation requiring overnight call was also associated with burnout (ORs 1.69 and 1.48, respectively; both P  ≤ 0.02). Other workload characteristics (e.g. number of admissions) had no relation to student burnout. Students who experienced a positive personal life event had a lower frequency of burnout (OR 0.70; P  ≤ 0.02), whereas those who experienced negative personal life events did not have a higher frequency of burnout than students who did not experience a negative personal life event. On multivariate analysis personal characteristics, learning environment and personal life events were all independently related to student burnout.
Conclusions  Although a complex array of personal and professional factors influence student well-being, student satisfaction with specific characteristics of the learning environment appears to be a critical factor. Studies determining how to create a learning environment that cultivates student well-being are needed.     

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.     

Marginalisation of dental students in a shared medical and dental education programme

Objectives  Internationally, there are a number of universities at which medical and dental education programmes share common elements. There are no studies about the experiences of medical and dental students enrolled in different programmes who share significant amounts of learning and teaching.
Methods  Semi-structured interviews and focus groups were conducted with 36 students and staff in a learning programme shared between separate medical and dental faculties. They were transcribed and an iterative process of interpretation and analysis within the theoretical framework of the contact hypothesis and social identity theory was used to group data into themes and sub-themes.
Results  Dental students felt 'marginalised' and felt they were treated as 'second-class citizens' by medical students and medical staff in the shared aspects of their programmes. Contextual factors such as the geographical location of the two schools, a medical : dental student ratio of almost 3 : 1, along with organisational factors such as curriculum overload, propagated negative attitudes towards and professional stereotyping of the dental students. Lack of understanding by medical students and faculty of dental professional roles contributed further.
Conclusions  Recommendations for reducing the marginalisation of dental students in this setting include improving communication between faculties and facilitating experiential contact. This might be achieved through initiating a common orientation session, stronger social networks and integrated learning activities, such as interprofessional problem-based learning and shared clinical experiences.     

Endotracheal intubation skills of medical students.

The ability and confidence of clinical medical students to insert endotracheal tubes correctly and quickly and to recognize oesophageal misplacement was evaluated. Ten (33%) of the medical students intubated the trachea correctly at their first attempt but 14 (47%) incorrectly identified the position of the endotracheal tube. However, recognition improved by their second and third attempts (70% and 80% respectively). Ninety-three percent of students intubated correctly on their third attempt. Although medical students can obtain better results at correct tube placement with repeated attempts under optimum conditions--a practice effect--and do better at recognizing correct tube placement there is still a persistent failure to recognize endotracheal tube misplacement, ie oesophageal intubation. It is the ability to recognize oesophageal intubation promptly that is a life-saving skill. This essential skill should be taught during the introductory anaesthesia programme through the use of clinical patients.     

A randomized controlled study of portfolio learning in undergraduate cancer education

Portfolio learning has not previously been reported for clinical undergraduate teaching. This open randomized study aimed to assess the effect of portfolio learning in the teaching of oncology to medical students. The project aimed to provide the student with a holistic understanding of the impact of the disease and its treatment on the patient and family, and the natural history of malignant disease, through long-term personal experience of a cancer patient. All undergraduate medical students entering Clinical Studies in October 1992 at the University of Wales College of Medicine were randomized to a study or control group. Both groups continued with the standard curriculum. Each study-group student followed a patient with cancer for 9 months, supported by bi-monthly small-group tutorials. Tutors were either general practitioners or hospital consultants, not necessarily oncologists; each was supplied with a tutor's resource pack of key oncology review papers. Students recorded triggers to learning and key items in a personal learning portfolio. Students' performances in clinical examinations and the contents of their portfolio were assessed. Final assessment was by hidden questions in the objective structured clinical examination (OSCE) in the final degree examination, when students in the study group showed higher marks in factual knowledge of oncology, particularly amongst the weaker students ( P  = 0·01). Those submitting portfolios for formative assessment had higher overall marks than those in the study group who did not ( P  = 0·04), representing the more motivated students. The whole study group showed a beneficial trend in their knowledge of oncology.     

Competency-based learning in neonatology

An educational model integrating structured teaching with clinical experience, or clerkship, has been designed to enable students to learn the core knowledge, skills and attitudes necessary to care for the newborn. The programme is run for fifth year medical students as part of four, 9-week periods in Obstetrics and Gynaecology each year. A SCORPIO teaching session is held in week 1 to introduce students to the core competencies in the subject areas of newborn examination, breastfeeding, resuscitation, respiratory distress and anthropometry. Groups of four students rotate through each topic, which is conducted by a neonatologist or registrar in training. Eight problem-based learning sessions are held during weeks 2–9. Several students assess a clinical problem, identify learning issues and meet colleagues and a facilitator to share their learning experiences and resolve the problem. The clinical experience, or clerkship, is based in the neonatal nursery where 2–3 students spend a week consolidating their clinical and procedural skills. A study group was assessed at the end of the programme by an Objective Structured Clinical Examination (OSCE) and a Multiple Choice Questionnaire (MCQ). A control group did the same assessment in week 1. All students were asked to rate the educational value of the three learning methods on a 5-point Likert scale. The study group (   n = 20  ) achieved a mean composite mark of 66% (SD 10%). This was significantly higher (   P < 0.001  ) than that of the control group (   n = 18  ), mean 45% (SD 7%). All students (100%) rated the educational value of SCORPIO as high or very high, and the comparative rating for problem-based learning and clerkship was 65%, respectively. The programme was enthusiastically received by the students and resulted in mastery of a range of core competencies necessary for care of the newborn.     

Impact of training periods in the emergency department on the motivation of health care students to learn

Objectives  Motivation is one of the most important factors for learning and achievement. The perceived value of the task, perceptions of self-efficacy and beliefs about control of learning are the main determinants of motivation. They are highly influenced by the individual's personal history and especially by significant past experiences. We assessed the impact of training periods in the emergency department on the motivation of health care students to learn in the field of emergency medicine.
Methods  A survey was conducted in 2008 with 112 undergraduate medical students and 201 undergraduate nursing students attending an emergency medicine academic programme. At the beginning of the course, the students completed an anonymous 26-item questionnaire to assess their motivational orientations.
Results  Perceived task value was higher for students who had previously attended a training period in the emergency department ( P  = 0.002). Perceived self-efficacy was depressed when the respondent had been confronted with negative outcome events ( P  < 0.001). Control of learning beliefs was affected negatively in students who had attended a training period in the emergency department ( P  < 0.001).
Conclusions  Motivation is a major contributor to the success of learning. Training periods in the emergency department can have positive and negative impacts on the learning motivation of medical and nursing students in the field of emergency medicine. Ideally, and in terms of increasing motivation, health care students should gain experiential learning in the emergency department before attending a corresponding academic course. During this period, tutors should provide appropriate supervision and feedback in order to support self-efficacy perception and learning control beliefs.     

A model of clinical problem-based learning for clinical attachments in medicine

Context  Problem-based learning (PBL) has been widely adopted in medical curricula for early-years training, but its use during clinical attachments has not been extensively explored.
Objectives  This study aimed to develop and evaluate a new model, 'clinical problem-based learning' (CPBL), to promote learning skills, attitudes and knowledge during clinical attachments.
Methods  The CPBL model takes the principles of PBL and applies them to learning during clinical attachments. Real patient encounters are guided by a list of broadly defined case types to ensure curriculum coverage. By discussing history taking and examination in the context of differential diagnosis and problem listing, students generate learning objectives relating to clinical skills, disease mechanisms and clinical management. These are explored through self-directed learning before the second tutorial, in which the tutor takes the role of 'expert', demonstrating how learned material translates into clinical practice. We evaluated which components contributed most to the success of the model using semi-structured questionnaires, focus groups and a consensus (Delphi process) method.
Results  Students found CPBL a positive learning experience. Identification of suitable cases for discussion was readily achieved, although follow-up was sometimes difficult. The tutor's level of expertise and a non-threatening learning environment, conducive to student questioning, were highly rated contributors to successful CPBL. Comments reinforced the view that CPBL is a parallel teaching approach that helps structure the teaching week, but does not replace traditional bedside teaching.
Conclusions  Clinical problem-based learning was well received in clinical placements. Key elements were the learning interval, the involvement of expert tutors and a non-threatening learning environment.     

北京市初中生学习困难现况

目的 筛查北京市初中学生学习困难发生率及分布情况,为后续相关研究和政策制定提供参考.方法 于2019年10月到2020年1月,采用分层随机整群抽样方法,选取北京市城乡12所公立普通初中的初一、初二年级6365名全体学生作为研究对象.使用联合型瑞文智力测验、主课成绩收集、教师判定等方法筛查学习困难学生.结果 由教师对研究...     

Innovative model for clinical education in dietetics

Aim:  Professional practice placement programs in dietetics face a number of challenges in respect of quantity, quality and sustainability. The aim of the present study is to report on the development of an innovative placement model based on a variety of training and supervision approaches to address these aforementioned challenges.
Methods:  The model was developed following an investigation of existing practice and the literature with approaches that were identified as important to the requirements and constraints of dietetics clinical training incorporated into the model.
Results:  Although one-on-one supervision is the predominant approach in Australian dietetic education, the educational literature and the authors' experience showed that a variety of approaches are represented in some form. The model developed involves the pairing of two students with one supervisor with students changing peer partners and supervisors every three weeks during the nine-week placement to diversify exposure to working and learning styles. The model integrates four customised approaches: incremental exposure to tasks; use of a clinical reasoning framework to help structure student understanding of the methods and judgements involved in patient care; structured enquiry in group discussions; and peer observation and feedback.
Conclusions:  The model has potential to achieve efficiencies in supervisors' involvement by coordinating the skill development activities of students as a group and promoting peer-assisted learning.     

How effective is self‐guided learning of clinical technical skills? It’s all about process

Objectives  Mounting evidence suggests that trainees acquire psychomotor skills better when they are allowed self-guided access to instructional material and when they set goals that are related to performance processes rather than performance outcomes. The present study assessed whether self-guided access to instruction and the setting of process goals lead to better acquisition of clinical technical skills.
Methods  To learn wound closure skills, 48 medical students were randomly assigned to one of four groups in a 2 × 2 study design. Self-guided participants were able to access the instructional video freely, whereas control participants were restricted to watching only those video segments accessed by their matched self-guided participant. Each group was further divided into two subgroups, comprising a process goal subgroup, where participants set goals focused on performance mechanisms, and an outcome goal subgroup, where participants set goals focused on performance products. Performance on pre-, post-, retention and transfer tests was assessed with hand motion measures and expert evaluations. Group differences were evaluated using one-way anova s.
Results  The self-guided group with process goals showed greater skill retention than its matched control group, whereas the self-guided group with outcome goals did not. Furthermore, the groups with process goals performed better on the transfer test than the outcome goal groups. Outcome goal participants accessed the instructional video most frequently.
Conclusions  Our findings advance the study of independent learning in medical education. Trainees used interactive and structured instructional materials to effectively self-guide their learning of clinical technical skills. However, a self-guided benefit was demonstrated only when trainees set process goals.     

Impact of problem-based, active learning on graduation rates for 10 generations of Dutch medical students

Objectives  We aimed to study the effects of active-learning curricula on graduation rates of students and on the length of time needed to graduate.
Methods  Graduation rates for 10 generations of students enrolling in the eight Dutch medical schools between 1989 and 1998 were analysed. In addition, time needed to graduate was recorded. Three of the eight schools had curricula emphasising active learning, small-group instruction and limited numbers of lectures; the other five had conventional curricula to varying degrees.
Results  Overall, the active-learning curricula graduated on average 8% more students per year, and these students graduated on average 5 months earlier than their colleagues from conventional curricula.
Conclusions  Four hypotheses potentially explaining the effect of active learning on graduation rate and study duration were considered: (i) active-learning curricula promote the social and academic integration of students; (ii) active-learning curricula attract brighter students; (iii) active-learning curricula retain more poor students, and (iv) the active engagement of students with their study required by active-learning curricula induces better academic performance and, hence, lower dropout rates. The first three hypotheses had to be rejected. It was concluded that the better-learning hypothesis provides the most parsimonious account for the data.     

Contribution of medical students to admission interviews

Objective  Medical students were included in 3-person interview panels selecting applicants for a 4-year medical programme for graduates and health professionals. We analysed student contributions to the interview panels.
Methods  A total of 188 semi-structured interviews were carried out over 2 years. The scores of 17 student interviewers were compared with those of the other 2 members of the panels.
Results  Students were positive about the interview process and their involvement. Overall interview scores did not differ between students and other interviewers. However, students gave lower scores overall and in a number of individual areas to those who had the highest consensus scores and were offered places on the programme. Students were more likely than other interviewers to be indecisive between 2 scores (25.2% versus 17.5%; P  <   0.01).
Conclusions  Students can be integrated effectively into the interview process. However, they tend to be more reluctant to give high scores and less decisive about committing to a single score than more experienced interviewers. Students value the experience of participating in the selection process, especially when combined with an exploration of the literature related to selection procedures.