Medical students' self-assessments and their allocations of learning time.

PURPOSE: To investigate the impact of self-assessed diagnostic strengths and weaknesses on medical students' allocation of learning time (one indicator of self-directed learning) during a third-year internal medicine clerkship. METHOD: In 1997-98, 107 students at the University of Michigan Medical School self-assessed their diagnostic skills in 14 clinical areas before and after the clerkship and reported the relative amounts of time spent learning about these topics during the clerkship. RESULTS: Individual-level analyses indicated that, for the average student, self-assessed strengths and weaknesses did not correlate with allocation of educational time, but that time allocation was positively related to changes in self-assessed skill. Considerable variations in these relationships, however, suggest a need for closer study. CONCLUSION: Although individual students evidenced different levels of self-directed learning, this study suggests overall that students at this level of training are neophytes in applying both information generated through self-assessment and principles of self-directed learning in their clinical education. Attempts to advance students beyond this level depend on many factors, including the extent to which the learning environment encourages or even permits self-directed learning, the progression and time frame through which students become self-directed practitioners, and the impact of educational interventions to promote this development.     

A medical humanities special study module on principles of medical theory and practice at the Charité, Humboldt University, Berlin, Germany.

The authors are members of a committee in charge of a special study module (SSM) entitled Principles of Medical Theory and Practice in a problem-based and integrated reformed curriculum track at the Charité, the medical school and university hospital of the Humboldt University, Berlin, Germany. The SSM contextualizes medicine by highlighting the societal contexts of the doctor-patient relationship and the medical profession. Integrating the humanities into medical education helps students develop an awareness of the strengths and limitations of modern medicine, develop their own personalities and sense of social responsibility, and generally broaden their outlook. Teachers in the SSM seminars are from different disciplines, such as the history of medicine, bioethics, sociology, anthropology, and complementary medicine. Once a week, one or two teachers meet with as many as 21 students per group for a 90-minute course. Twelve courses constitute a seminar. Students are required to participate in four seminars during five years of studies. They can choose different topics from a set range. Although this SSM has been largely successful, some problems have occurred. Results from the course evaluations and experiences show that the seminars differ from one another in many ways. Financial restraints and the departmental structure of the faculty have influenced implementation of the SSM. However, the SSM is a new concept and is continuously reviewed and renewed. Future plans will be to specify outcomes, continue to discuss reasonable seminar topics, establish continuous support and training for teachers, and motivate students to become actively involved in the seminar discussions.     

Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores?

PURPOSE: Faculty development programs and faculty incentive systems have heightened the need to validate a connection between the quality of teaching and students' learning. This study was designed to determine the association between attending physicians' and residents' teacher ratings and their students' examination scores. METHOD: From a database of 362 students, 138 faculty, and 107 residents in internal medicine, student-faculty (n = 476) and student-resident (n = 474) pairs were identified. All students were in their third year, rotating on inpatient general medicine and cardiology services, July 1994 through June 1996, at a single institution. The outcome measure for students' knowledge was the NBME Subject Examination in internal medicine. To control for students' baseline knowledge, the predictors were scores on the USMLE Step 1 and a sequential examination (a clinically-based pre- and post-clerkship examination). Teaching abilities of faculty and residents were rated by a global item on the post-clerkship evaluation. Faculty's ratings used only scores from prior to the study period; residents' ratings included those scores students gave during the study period. RESULTS: Multivariate analyses showed faculty's teaching ratings were a small but significant predictor of the increase in students' knowledge. Residents' teaching ratings did not predict an increase in students' knowledge. CONCLUSION: Attending faculty's clinical teaching ability has a positive and significant effect on medical students' learning.     

Using a web-based, iterative education model to enhance clinical clerkships.

Although most clinical clerkship curricula are designed to provide all students consistent exposure to defined course objectives, it is clear that individual students are diverse in their backgrounds and baseline knowledge. Ideally, the learning process should be individualized towards the strengths and weakness of each student, but, until recently, this has proved prohibitively time-consuming. The authors describe a program to develop and evaluate an iterative, Web-based educational model assessing medical students' knowledge deficits and allowing targeted teaching shortly after their identification. Beginning in 2002, a new educational model was created, validated, and applied in a prospective fashion to medical students during an internal medicine clerkship at Harvard Medical School. Using a Web-based platform, five validated questions were delivered weekly and a specific knowledge deficiency identified. Teaching targeted to the deficiency was provided to an intervention cohort of five to seven students in each clerkship, though not to controls (the remaining 7-10 students). Effectiveness of this model was assessed by performance on the following week's posttest question. Specific deficiencies were readily identified weekly using this model. Throughout the year, however, deficiencies varied unpredictably. Teaching targeted to deficiencies resulted in significantly better performance on follow-up questioning compared to the performance of those who did not receive this intervention. This model was easily applied in an additive fashion to the current curriculum, and student acceptance was high. The authors conclude that a Web-based, iterative assessment model can effectively target specific curricular needs unique to each group; focus teaching in a rapid, formative, and highly efficient manner; and may improve the efficiency of traditional clerkship teaching.     

Effect of an evidence-based medicine seminar on participants' interpretations of clinical trials: a pilot study.

PURPOSE: To evaluate the effect of evidence-based medicine (EBM) education on physicians' short-term and long-term understanding of research methods and statistics. METHOD: Twenty-four gastroenterology (GI) fellows attended a three-day seminar about evidence-based medicine and the critical appraisal of medical literature. Attendees completed the same 14-item test on this material at the start of the seminar, at the conclusion of the seminar, and six months after the seminar. A student's t-test and chi-square analysis were performed to determine the differences between test scores by testing date and performance on test items. RESULTS: Seminar attendees improved their test scores between pre-seminar and post-seminar tests (mean test score: 57% +/- 16% versus 82 +/- 14%, respectively; p <.001) and between pre-seminar and six-month post-seminar tests (mean test score: 57% +/- 16% versus 78% +/- 13%, respectively; p <.001). Seminar attendees showed significant improvement in frequency of correct answers with individual questions on concealment of allocation, relative risk reduction, and meta-analysis trial methods. CONCLUSIONS: In this pilot study, the critical appraisal skills necessary to practice EBM were taught to GI fellows in a seminar format that led to significant improvement in their understanding of research methods and statistics. Data from this pilot study justify a definitive trial examining the educational value of EBM seminars for physicians.     

Medical humanities: a new undergraduate teaching program at the University of Geneva School of Medicine, Switzerland.

In 2001, a new program of medical humanities was initiated at the University of Geneva School of Medicine in Switzerland. Four mandatory seminars and one optional 2-week internship are offered to second-through fifth-year medical students. The program has four interdependent goals: contextualizing, developing personal reflection and judgment, encouraging imagination, and offering specific ways to improve the quality of the therapeutic relationship. The program is based on an integrated vision of the humanities and stimulates the students' imagination and reflection in a way that medical students should find useful. Three steps help teachers to build an integrated vision: familiarization, confrontation, and adjustment to the medical culture. The mandatory seminars are taught by a team consisting of a physician and a humanities teacher. All the physicians, department heads, and clinicians involved in each seminar actively collaborated. The medical humanities program is in the Bioethics Unit, which is housed in the Department of Community Health and Medicine with medical history and legal medicine. This intellectual, institutional, and physical proximity encourages informal dialogue and ensures a more coherent and unified vision of the different disciplines. In their assessments of the program, students stated that the seminars gave them food for thought and met their expectations. However, it is premature to draw conclusions from these assessments because the program is still in its infancy. The program strives to provide students with tools specific to the humanities so that they can strengthen their own judgment, listening skills, open-mindedness, creativity, and curiosity, attributes that are needed to ensure that the therapeutic relationship will be satisfying for both physicians and patients.     

The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education.

The Harvard Medical School-Cambridge Integrated Clerkship (HMS-CIC) is a redesign of the principal clinical year to foster students' learning from close and continuous contact with cohorts of patients in the disciplines of internal medicine, neurology, obstetrics-gynecology, pediatrics, and psychiatry. With year-long mentoring, students follow their patients through major venues of care. Surgery and radiology also are taught longitudinally, grounded in the clinical experiences of a cohort of patients and in a brief immersion experience working directly with an attending surgeon. Students participate in weekly, case-based tutorials integrating instruction in the basic sciences with training to address the common and important issues in medicine, as identified by national organizations. In addition, they participate in a social science curriculum that focuses on self-reflection, communication skills, ethics, population sciences, and cultural competence. In the pilot year (July 2004 to July 2005), HMS-CIC students performed at least as well as traditional students in tests of content knowledge and skills, as measured by National Board of Medical Examiners (NBME) Subject Exams and the fourth-year Objective Structured Clinical Exam, and they scored higher on a year-end comprehensive clinical skills self-assessment examination, suggesting that they retained content knowledge better. From surveys, HMS-CIC students were much more likely to see patients before diagnosis and after discharge and to receive feedback and mentoring from experienced faculty than were their traditionally educated peers. HMS-CIC students expressed more satisfaction with their curriculum and felt better prepared to cope with the professional challenges of patient care, such as being truly caring, involving patients in decision making, and understanding how the social context affects their patients.     

Perceptions and attributions of third-year student struggles in clerkships: do students and clerkship directors agree?

PURPOSE: To explore the congruence between students' and clerkship directors' perceptions and attributions of students' struggles during the transition to clerkships. METHOD: Focus groups and interviews were conducted with third- and fourth-year medical students and clerkship directors at 10 U.S. medical schools in 2005 and 2006. Schools were selected to represent diverse locations, sizes, and missions. Interviews and focus groups were recorded, transcribed, and analyzed thematically. RESULTS: Students' struggles included understanding roles and responsibilities, adjusting to clinical cultures, performing clinical skills, learning the logistics of clinical settings, and encountering frequent changes in staff, settings, and content. Clerkship directors recognized students' struggles with roles and responsibilities, performing clinical skills, and adjusting to clinical cultures, but they also focused on students' difficulties applying knowledge to clinical reasoning and engaging in self-directed learning. CONCLUSIONS: Clerkship directors and students recognize many challenges associated with learning and performing in the clerkships. Students' perspectives suggest that these challenges may be more complex than clerkship directors and clinical teachers realize and/or are capable of addressing. The areas in which clerkship directors' and students' perspectives are not congruent point to directions for future research that can guide curricula and teaching strategies.     

Virtual Patients in Primary Care: Developing a Reusable Model That Fosters Reflective Practice and Clinical Reasoning

Background

Primary care is an integral part of the medical curriculum at Karolinska Institutet, Sweden. It is present at every stage of the students’ education. Virtual patients (VPs) may support learning processes and be a valuable complement in teaching communication skills, patient-centeredness, clinical reasoning, and reflective thinking. Current literature on virtual patients lacks reports on how to design and use virtual patients with a primary care perspective.

Objective

The objective of this study was to create a model for a virtual patient in primary care that facilitates medical students’ reflective practice and clinical reasoning. The main research question was how to design a virtual patient model with embedded process skills suitable for primary care education.

Methods

The VP model was developed using the Open Tufts University Sciences Knowledgebase (OpenTUSK) virtual patient system as a prototyping tool. Both the VP model and the case created using the developed model were validated by a group of 10 experienced primary care physicians and then further improved by a work group of faculty involved in the medical program. The students’ opinions on the VP were investigated through focus group interviews with 14 students and the results analyzed using content analysis.

Results

The VP primary care model was based on a patient-centered model of consultation modified according to the Calgary-Cambridge Guides, and the learning outcomes of the study program in medicine were taken into account. The VP primary care model is based on Kolb’s learning theories and consists of several learning cycles. Each learning cycle includes a didactic inventory and then provides the student with a concrete experience (video, pictures, and other material) and preformulated feedback. The students’ learning process was visualized by requiring the students to expose their clinical reasoning and reflections in-action in every learning cycle. Content analysis of the focus group interviews showed good acceptance of the model by students. The VP was regarded as an intermediate learning activity and a complement to both the theoretical and the clinical part of the education, filling out gaps in clinical knowledge. The content of the VP case was regarded as authentic and the students appreciated the immediate feedback. The students found the structure of the model interactive and easy to follow. The students also reported that the VP case supported their self-directed learning and reflective ability.

Conclusions

We have built a new VP model for primary care with embedded communication training and iterated learning cycles that in pilot testing showed good acceptance by students, supporting their self-directed learning and reflective thinking.     

Seminar in breast self-examination for female medical students integrated into a human gross anatomy course

A breast self-examination (BSE) seminar for first-year female medical students is presented and a single-gender approach for other subjects in the medical curriculum is discussed. In 1999 a small group seminar on BSE was offered at the Hannover Medical School to female medical students as part of their curriculum in human gross anatomy. An evaluation questionnaire was answered by 94 students (87% of participants). Frequencies of answers to two open questions were used as indicators of: 1) the acceptance of a single-gender course and 2) an increased awareness of breast cancer prevention. A linear regression analysis was carried out to identify the most important predictors for the global course evaluation and a heightened interest in breast cancer prevention. The mean global rating of the seminar was 13.8 (minimum: 1 point; maximum: 15 points). Factors that significantly influenced the global rating were the course atmosphere, the teacher's enthusiasm, and the professional interest of the students. An increased concern for breast cancer prevention was significantly dependent on the professional interest and the self-awareness of the women. The results suggest that there is a need for single-gender seminars in academic medicine and that instruction of female students in BSE is an ideal subject for this approach. Because of the prevalence of breast cancer, it is recommended that such a seminar become an integral part of the preclinical curriculum for all female medical students.     

The impact of preclinical preceptorships on learning the fundamentals of clinical medicine and physical diagnosis skills.

PURPOSE: To learn whether preclinical primary care preceptorships resulted in demonstrable clinical performance benefits to medical students. METHOD: This was a retrospective cohort study of 267 medical students who elected and 310 students who did not elect to take a four-week primary care preceptorship following the first year of training at the University of Texas Medical School at Houston in 2001-2003. Outcome variables were the students' performances on a written examination testing their integration of basic science and fundamentals of clinical medicine and performances on a comprehensive objective structured clinical examination (OSCE). After adjusting for factors that might have explained differences in the students' performances, logistic regression models were used to assess the association of the outcome variables with participation in a preceptorship. RESULTS: Students who participated in any one of the preceptorships performed better on the OSCE and on the fundamentals of clinical medicine examination than students who did not participate (p < .01). Students who participated in the family medicine or pediatric preceptorship scored higher on an OSCE (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.01-2.78 and OR, 2.26; 95% CI, 1.18-4.36, respectively) than those students who did not participate in a preceptorship. Students who participated in the internal medicine preceptorship scored higher on the fundamentals of clinical medicine examination (OR, 3.18; 95% CI, 1.92-5.23). CONCLUSIONS: Preliminary evidence indicates that a short preclinical primary care preceptorship can help medical students to consolidate and integrate the fundamental cognitive and clinical skills they will apply during the clinical years of medical training.     

The use of questionnaires to assess achievement of course goals in medical students' longitudinal community-based clinical experiences.

PURPOSE: To examine the usefulness of questionnaires for assessing achievement of course goals in medical students' longitudinal community-based clinical experiences. METHOD: In 1997, the authors surveyed 114 first-year students and their preceptors in a longitudinal community-based program at The Joan and Sanford I. Weill Medical College of Cornell University. The questionnaire used a Likert scale to assess students' and preceptors' pre-course expectations for achieving specific course goals and their post-course perceptions of having met those goals. The students also rated global learning and satisfaction during each office preceptor session, and faculty assessed the students' physical examination skills at the end of the course. RESULTS: For all goals assessed, the preceptors scored their students' achievement of course goals significantly higher than did the students themselves (p < .01). The students invariably scored their post-course perceptions of having achieved the goals lower than they did their pre-course expectations (p < .001). Before the course, the preceptors were confident in their ability to teach the curricular material; this confidence remained after the course. Global learning and satisfaction scores were high and all students performed satisfactorily in the demonstration examination. CONCLUSIONS: Students and preceptors may not agree on students' achievement of course goals. Furthermore, despite students' high ratings of global satisfaction and learning, and despite their satisfactory performance of physical examination skills, their ratings of post-course performance may be affected by pre-course expectations. The authors suggest that questionnaires assessing students' and preceptors' perceptions of students' achievement of specific goals should be independently verified before making decisions to modify objectives and activities in these kinds of courses.     

The psychological basis of problem-based learning: a review of the evidence.

Several potential advantages for students' learning are claimed for problem-based learning (PBL). Students in PBL curricula may be more highly motivated; they may be better problem solvers and self-directed learners; they may be better able to learn and recall information; and they may be better able to integrate basic science knowledge into the solutions of clinical problems. Although some of these claims find theoretical support from the literature on the psychology of learning, to date there has been no review of the experimental evidence supporting the possible differences in students' learning that can be attributed to PBL. In this review article, the authors examine each claim critically in light of that evidence. They conclude that (1) there is no evidence that PBL curricula result in any improvement in general, content-free problem-solving skills; (2) learning in a PBL format may initially reduce levels of learning but may foster, over periods up to several years, increased retention of knowledge; (3) some preliminary evidence suggests that PBL curricula may enhance both transfer of concepts to new problems and integration of basic science concepts into clinical problems; (4) PBL enhances intrinsic interest in the subject matter; and (5) PBL appears to enhance self-directed learning skills, and this enhancement may be maintained.     

伦理学在生殖医学教学中的实践及体会

生殖医学是一门牵扯生殖医学、内分泌学、遗传学、伦理学等的复杂知识的前沿学科,且涉及人类繁衍,牵涉众多伦理问题,为生殖医学的教学提供挑战和难度。伦理学虽然已经在众多医学院校设为教学课程,但教学多浮于理论,无法激发学生学习兴趣,增加学习深度。本文从医学伦理知识讲授者的知识储备、临床病例分析学习及临床科研教学方面的伦理实践三个方面探究了如何更好的在生殖医学教学工作中提高医学伦理的重要性,加强伦理学的教学效果。     

关于高职高专医学院校《物理》课程教学的探讨

物理学作为医学院校开设的一门重要的基础课程,不仅是学习后继课程的基础,也是培养学生科学素质,提高人才质量的重要学科。本文结合目前医学院校学生特点,从评估学生已有知识、提高学生学习兴趣、采取多种教学方式等方面来探讨如何提高医学院校《物理》课程的教学质量,以培养具有一定物理学基础知识的高素质医学人才。     

The need for education on health related-quality of life

Background

Health-related quality of life is increasingly recognised as an important outcome measure that complements existing measures of clinical effectiveness. The education available on this subject for different healthcare professionals is varied. This article describes the design, implementation and evaluation of a Special Study Module on Health-Related Quality of Life for undergraduate medical students at the University of Birmingham.

Methods

The course involves 10 hours of "guided discovery learning" covering core concepts of Health-Related Quality of Life assessment including methodological considerations, use in clinical trials, routine practice and in health policy followed by self-directed learning. The taught components aim to provide students with the skills and knowledge to enable them to explore and evaluate the use of quality of life assessments in a particular patient group, or setting, through self-directed learning supported by tutorials.

Results

The use of case studies, recent publications and research, and discussion with a research oncology nurse in task-based learning appeared to provide students with a stimulating environment in which to develop their ideas and was reflected in the diverse range of subjects chosen by students for self-directed study and the positive feedback on the module. Course evaluation and student assessment suggests that quality of life education appears to integrate well within the medical curriculum and allows students to develop and utilise skills of time-management and independent, self-directed learning that can be applied in any context.

Conclusion

We suggest that education and training initiatives in quality of life may improve the quality of studies, and help bridge the gap between research and clinical practice. Resources for curriculum development on health-related quality of life have been developed by the International Society for Quality of Life Research and may prove a useful tool to educators interested in this area.     

Interactive seminars or small group tutorials in preclinical medical education: results of a randomized controlled trial

Background  

Learning in small group tutorials is appreciated by students and effective in the acquisition of clinical problem-solving skills but poses financial and resource challenges. Interactive seminars, which accommodate large groups, might be an alternative. This study examines the educational effectiveness of small group tutorials and interactive seminars and students' preferences for and satisfaction with these formats.     

The influence of task formats on the accuracy of medical students' self-assessments.

PURPOSE: Accurate self-assessment is an essential skill for the self-directed learning activities and appropriate patient referral decisions of practicing physicians. However, many questions about the characteristics of self-assessment remain unanswered. One is whether self-assessment is a generalizable skill or dependent on the characteristics of the task. This study examines the self-assessment skills of medical students across two task formats: performance-based and cognitive-based. METHOD: In 1997 and 1998, fourth-year medical students at the University of Michigan assessed their own performances on ten stations of a clinical examination. The examination used two formats: performance tasks (the examination or history taking of standardized patients) and cognitive tasks (interpreting vignettes or test results and then answering paper-and-pencil questions). Three measures of self-assessment accuracy were used: a bias index (average difference between the students' estimates of their performances and their actual scores), a deviation index (average absolute difference between estimate and actual score), and an actual score-estimate-of-performance correlation (the correlation between the estimate and actual scores). RESULTS: The student bias and deviation indices were similar on the cognitive and the performance tasks. The correlations also indicated similarity between the two types of tasks. CONCLUSION: The results indicate that the format of the task does not influence students' abilities to self-assess their performances, and that students' self-assessment abilities are consistent over a range of skills and tasks. The authors also emphasize the importance of sampling tasks while conducting self-assessment research.     

Weaving basic and social sciences into a case-based, clinically oriented medical curriculum: one school's approach.

Southern Illinois University School of Medicine recently completed its fourth year of a resource-session-enhanced, case-based, tutor-group-oriented curriculum. As an example of a curricular unit, the authors describe the implementation of the basic and clinical sciences in one of the four units in year one, and detail that unit's organization, logistics, content, rationale, and other characteristics. The Sensorimotor Systems and Behavior (SSB) unit is preceded by a cardio-respiratory-renal unit and is followed by an endocrine-reproductive-gastrointestinal unit. A Doctoring unit temporally spans each of these three units. The SSB unit is allotted an 11.5-week period that includes an aggregate of 2.5 weeks of available clinical time, 1.5 weeks for examinations and exam study time, and approximately 8.5 weeks for tutor-group sessions, mandatory laboratory sessions, and self-directed learning. Optional resource sessions are offered during a two- to four-hour block on a single morning each week. Clinical training in the SSB unit augments self-directed, laboratory, and tutor-group learning of neuroscience, gross anatomy, cell biology, physiology, biochemistry, behavioral and social science, embryology, limited pharmacology and genetics, and basic clinical neurology for first-year students. Although it is fast-paced and places heavy responsibility for independent learning on the students, the SSB unit culminates in significant achievement in the basic and clinical sciences. The unit provides substantial clinical training and practical experience in physical and neurological examinations that directly integrate with basic science knowledge. The unit reduces lecture-based instruction, demands self-determination, and promotes experience in team effort, professionalism, peer interaction, empathy in clinical medicine, and practical use of basic science knowledge.     

Impact of problem-based learning on the cognitive processes of medical students

The problem based learning (PBL) method was conceived as a teaching strategy to be applied in different areas or disciplines, thus several universities adopted it, among which was the Universidad Nacional Autónoma de México, best known as UNAM. The Faculty of Medicine of UNAM implemented this innovative teaching method of medicine for its learner-centered educational method tendency (patient-centered practice). This method develops also several abilities in the students, such as active and significant learning, seeking and data selection and autoanalysis and synthesis, knowledge integration of, mind's logic for the detection and solution of problems, among others. The aim was to evaluate the PBL impact on pedagogical and cognitive processes through the students' critical thinking and the significance of the experience on students and teachers which were working with PBL; in addition, study strategies and self-regulation in students were considered variables for the study. Our findings indicated that PBL was perceived differently among students and teachers, and it influenced in a positive and significant way the students' perception to solve problems and their motivation to achieve a good academic performance (p < 0.005). These results suggest that PBL is a useful strategy in the teaching and learning process and it is clear that the pedagogical process and other variables can potentially influence the results obtained.