Student evaluation of the clinical 'curriculum in action'

AIM: To examine how students' evaluations of the environment, process and outcome of clinical learning interrelated and correlated with assessment results. METHOD: A post hoc study in the 3rd of 5 years in a student-centred, horizontally integrated, objective-based medical curriculum. In the last week of each module, students evaluated what they had learned and how they had learned it using a previously validated, web-based scale. The interrelationships between scale variables and their relationships with summative assessment results were tested using factor analysis, correlation analysis and stepwise multiple regression analysis. RESULTS: Student evaluation yielded 4 summary measures: 2 reflected learning outcomes ('real patient learning' and 'curriculum coverage'), 1 reflected process ('quality of instruction') and 1 reflected environment ('conditions for learning'). They fitted a causal model according to which instruction, conditions for learning and curriculum coverage favoured real patient learning. Real patient learning was rated higher in women than men, and the measures were associated more strongly in women. Performance in end-of-year summative assessments was predicted strongly by mid-year performance but by no other measure. CONCLUSIONS: Students' evaluations of their learning environment and instructional processes correlated with their assessments of 2 outcomes of the curriculum in action: curriculum coverage and real patient learning. There was little shared variance between those measures and students' performance in summative assessments. Given its formative potential, students' evaluation of their curriculum in action could play a useful part in learner-centred clinical education. There is a possibility, which needs further research, that women's evaluations have greater predictive validity than men's. Assessment performance should be regarded not as a solitary gold standard but as just 1 measure of educational outcome.     

The impact of intrapartum analgesia on infant feeding

OBJECTIVE: To investigate the impact of intrapartum analgesia on infant feeding at hospital discharge. DESIGN: Retrospective cohort. SETTING: Maternity unit of a UK district general hospital. POPULATION: A random sample of 425 healthy primiparae delivering healthy singleton babies at term in 2000. METHODS: A random sample of primiparae delivering term neonates was identified from the birth register. We retrieved and analysed the corresponding joint midwifery/obstetric case notes. MAIN OUTCOME MEASURE: Infant feeding method at discharge from hospital. RESULTS: Women [190/424 (45%)] were exclusively bottle feeding their babies at discharge from hospital. No one commenced breastfeeding after hospital discharge. Regression analysis revealed that the main determinants of bottle feeding were as follows: maternal age [odds ratio (OR) 0.90, 95% confidence interval [CI] 0.85-0.95 per year]; occupation (OR 0.63, 95% CI 0.40-0.99 for each category, unemployed, manual, non-manual); antenatal feeding intentions (OR 0.12, 95% CI 0.080-0.19 for each category, bottle feeding, undecided, breastfeeding); caesarean section (OR 0.25, 95% CI 0.13-0.47, caesarean or vaginal delivery); and dose of fentanyl administered intrapartum (OR 1.004, 95% CI 1.000-1.008, 90% CI 1.001-1.007 for each microgram administered, range 8-500 mug). CONCLUSIONS: A dose-response relationship between fentanyl and artificial feeding has not been reported elsewhere. When well-established determinants of infant feeding are accounted for, intrapartum fentanyl may impede establishment of breastfeeding, particularly at higher doses.     

Does reflection have an effect upon case-solving abilities of undergraduate medical students?

ABSTRACT: BACKGROUND: Reflection on professional experience is increasingly accepted as a critical attribute for health care practice; however, evidence that it has a positive impact on performance remains scarce. This study investigated whether, after allowing for the effects of knowledge and consultation skills, reflection had an independent effect on students' ability to solve problem cases. METHODS: Data was collected from 362 undergraduate medical students at Ghent University solving video cases and reflected on the experience of doing so. For knowledge and consultation skills results on a progress test and a course teaching consultation skills were used respectively. Stepwise multiple linear regression analysis was used to test the relationship between the quality of case-solving (dependent variable) and reflection skills, knowledge, and consultation skills (dependent variables). RESULTS: Only students with data on all variables available (n[THIN SPACE]=[THIN SPACE]270) were included for analysis. The model was significant (Anova F(3,269)[THIN SPACE]=[THIN SPACE]11.00, p[THIN SPACE]<[THIN SPACE]0.001, adjusted R square 0.10) with all variables significantly contributing. CONCLUSION: Medical students' reflection had a small but significant effect on case-solving, which supports reflection as an attribute for performance. These findings suggest that it would be worthwhile testing the effect of reflection skills training on clinical competence.     

Alcohol delays the emergence of the fetal elicited startle response, but only transiently

Prenatal exposure to alcohol may exert a significant detrimental effect on the functioning of the individual's brain, however few studies have examined this before birth. This longitudinal study examined the effect of maternal alcohol consumption on the elicited startle response of the fetus. Two groups of fetuses were examined: one whose mothers drank alcohol (approximately 10 units per week); the other whose mothers did not drink alcohol. Fetuses were examined at 29, 32 and 35 weeks gestation and their startle response observed using ultrasound in response to 2 presentations of a pink noise (70-250Hz) at 90dB(A) separated by 30s. Fetuses exposed to alcohol exhibited a weaker startle response at 29 weeks gestation than did fetuses not exposed to alcohol. There was no difference in the response at 32 and 35 weeks gestation. To ensure that the effects were not due to a more general effect of alcohol on fetal movement, a second experiment compared the spontaneous movements (observed on ultrasound for 45 min) of fetuses whose mothers drank alcohol and fetuses of mothers who didn't drink alcohol. There were no differences in movements exhibited by the fetuses. The results suggest that exposure to alcohol delays the emergence of the elicited startle response at 29 weeks gestation but this delay has disappeared by 32 weeks gestation. The possible role of altered neural development, acute exposure to alcohol and disruptions to the fetus's behavioural repertoire, in mediating these effects are discussed.     

Experiential learning: AMEE Guide No. 63

This Guide provides an overview of educational theory relevant to learning from experience. It considers experience gained in clinical workplaces from early medical student days through qualification to continuing professional development. Three key assumptions underpin the Guide: learning is 'situated'; it can be viewed either as an individual or a collective process; and the learning relevant to this Guide is triggered by authentic practice-based experiences. We first provide an overview of the guiding principles of experiential learning and significant historical contributions to its development as a theoretical perspective. We then discuss socio-cultural perspectives on experiential learning, highlighting their key tenets and drawing together common threads between theories. The second part of the Guide provides examples of learning from experience in practice to show how theoretical stances apply to clinical workplaces. Early experience, student clerkships and residency training are discussed in turn. We end with a summary of the current state of understanding.     

Focal segmental glomerulosclerosis in association with Gitelman syndrome

Gitelman syndrome (GS) is an autosomal recessive disorder characterized by hypokalemia, metabolic alkalosis, hypomagnesemia and hypocalciuria. Glomerulonephritis associated with GS is rarely documented in the literature. We present an adult patient with GS whose renal biopsy revealed focal segmental glomerulosclerosis.