Use of critical incidents to develop a rating form for resident evaluation of faculty teaching

CONTEXT: Monitoring the teaching effectiveness of attending physicians is important to enhancing the quality of graduate medical education. METHODS: We used a critical incident technique with 35 residents representing a cross-section of programmes in a teaching hospital to develop a 23-item rating form. We obtained ratings of 11 attending physicians in internal medicine and general surgery from 54 residents. We performed linear and logistic regression analysis to relate the items on the form to the residents' overall ratings of the attending physicians and the programme directors' ratings of the attending physicians. RESULTS: The residents rated the attending physicians highly in most areas, but lower in provision of feedback, clarity of written communication and cost-effectiveness in making clinical decisions. When we used the residents' overall ratings as the criterion, the most important aspects of attending physicians' teaching were clarity of written communication, cost-effectiveness, commitment of time and energy and whether the resident would refer a family member or friend to the physician. When we used the programme directors' ratings as the criterion, the additional important aspects of performance were concern for the residents' professional well-being, knowledge of the literature and the delivery of clear verbal and written communication. CONCLUSIONS: The critical incident technique can be used to develop an instrument that demonstrates content and construct validity. We found that residents consider commitment of time to teaching and clinical effectiveness to be the most important dimensions of faculty teaching. Other important dimensions include written and verbal communication, cost-effectiveness and concern for residents' professional development.     

Psychometric properties of an instrument to measure the clinical learning environment

OBJECTIVES: The clinical learning environment is an influential factor in work-based learning. Evaluation of this environment gives insight into the educational functioning of clinical departments. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an evaluation tool consisting of a validated questionnaire with 3 subscales. In this paper we further investigate the psychometric properties of the PHEEM. We set out to validate the 3 subscales and test the reliability of the PHEEM for both clerks (clinical medical students) and registrars (specialists in training). METHODS: Clerks and registrars from different hospitals and specialties filled out the PHEEM. To investigate the construct validity of the 3 subscales, we used an exploratory factor analysis followed by varimax rotation, and a cluster analysis known as Mokken scale analysis. We estimated the reliability of the questionnaire by means of variance components according to generalisability theory. RESULTS: A total of 256 clerks and 339 registrars filled out the questionnaire. The exploratory factor analysis plus varimax rotation suggested a 1-dimensional scale. The Mokken scale analysis confirmed this result. The reliability analysis showed a reliable outcome for 1 department with 14 clerks or 11 registrars. For multiple departments 3 respondents combined with 10 departments provide a reliable outcome for both groups. DISCUSSION: The PHEEM is a questionnaire measuring 1 dimension instead of the hypothesised 3 dimensions. The sample size required to achieve a reliable outcome is feasible. The instrument can be used to evaluate both single and multiple departments for both clerks and registrars.     

Becoming a new doctor: a learning or survival exercise?

OBJECTIVE: This study set out to establish why some new doctors view their training as a valuable period in their professional development, whereas others see it as a year to be endured and survived. METHODS: This multi-method case study focused on the interaction of key participants within 1 deanery, sampling the 237 pre-registration house officers (PRHOs) and 166 educational supervisors populating the associated 12 National Health Service trusts at the time (2001). The design of the case study was predicated on gathering the views of both teachers and learners in a way that allowed each stage of the data collection process to inform and influence the next phase. RESULTS: Lack of formal guidance and support were common characteristics associated with the first few days in post. The first day in post as a doctor is, for most, an experience that is hard to prepare for, even after a useful induction period. Those PRHOs who felt they were not guided or advised on how to undertake their new professional responsibilities tended to feel undervalued and under-recognised as individuals. CONCLUSIONS: Without the support of senior colleagues who can help the new doctor reflect on quite difficult and uncertain situations, new doctors will almost certainly perceive the first year of the new Foundation Programme as a survival exercise. If new doctors are working in an environment where their learning is properly facilitated, they are more likely to recognise their progress in their professional development and be more proactive in addressing concerns about professional expectations.     

Complexity, risk and simulation in learning procedural skills

BACKGROUND: A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learner's evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualize a dynamic awareness of prevailing risk and the implications of moving between zones. THE IMPORTANCE OF CONTEXT: We argue that clinical exposure can be consolidated by simulation where appropriate, ensuring that each learner gains the skills for safe care within the increasingly limited time available for training. To be effective, however, such simulation must be realistic, patient-focused, structured and grounded in an authentic clinical context. Challenge comes not only from technical difficulty but also from the need for interpersonal skills and professionalism within clinical encounters. PATIENT FOCUSED SIMULATION: Many existing simulations focus on crises, so clinicians are in a heightened state of expectation that may not reflect their usual practice. We argue that simulation should also reflect commonly occurring non-crisis situations, allowing clinicians to develop an awareness of the complex events that underpin clinical encounters. We describe a patient-focused approach to simulation, using simulated patients and inanimate models within realistic scenarios, to ground experience in authentic clinical practice and bring together the complex elements that underpin clinical events. APPLICATIONS: Although our argument has evolved from surgical practice and operating theatre teams, we believe it can be widely applied to the increasing number of health care professionals who perform clinical interventions.     

浅析中医妇科研究生医患沟通能力培养

中医妇科学是中医药临床主干课程之一,除注重培养中医妇科学研究生的临床操作技能和诊疗能力外,系统培养其医患沟通能力是其成长过程中的重要环节。本文对妇科临床教学遇到的中医妇科研究生医患沟通能力的现状和培养策略进行总结,为规范中医妇科研究生培养,提高实习基地教学质量提供参考。     

高等中医药院校提升医学研究生科研能力途径探索与实践

高等中医药院校培养的医学研究生,不仅要求具备扎实的专业知识、良好的的临床技能,也要求具备一定的科研素质。只有通过多途径的综合培养和管理,才能提高医学研究生科研能力,培养出综合素质全面的人才。本文结合我校实际,对医学研究生科研能力培养途径进行多层面、多渠道分析探讨,以确保医学研究生科研创新能力的提升。     

Components of postgraduate competence: analyses of thirty years of longitudinal data

CONTEXT: The conceptualisation and measurement of competence in patient care are critical to the design of medical education programmes and outcome assessment. OBJECTIVE: We aimed to examine the major components and correlates of postgraduate competence in patient care. METHODS: A 24-item rating form with additional questions about resident doctors' performance and future residency offers was used. Study participants comprised 4560 subjects who graduated from Jefferson Medical College between 1975 and 2004. They pursued their graduate medical education in 508 hospitals. We used a longitudinal study design in which the rating form was completed by programme directors to evaluate residents at the end of the first postgraduate year. Factor analysis was used to identify the underlying components of postgraduate ratings. Multiple regression, t-test and correlational analyses were used to study the validity of the components that emerged. RESULTS: Two major components emerged, which we labelled 'Knowledge and Clinical Capabilities' and 'Professionalism', and which addressed the science and art of medicine, respectively. Performance measures during medical school, scores on medical licensing examinations, and global assessment of Medical Knowledge, Clinical Judgement and Data-gathering Skills showed higher correlations with scores on the Knowledge and Clinical Capabilities component. Global assessments of Professional Attitudes and ratings of Empathic Behaviour showed higher correlations with scores on the Professionalism component. Offers of continued residency and evaluations of desirable qualities were associated with both components. CONCLUSIONS: Psychometric support for measuring the components of Knowledge and Clinical Capabilities, and Professionalism provides an instrument to empirically evaluate educational outcomes to medical educators who are in search of such a tool.     

论研究生培养的创新机制

第二军医大学研究生院成立六年来,以科学发展观为指导,坚持以“研究生为本”,注重观念创新、制度创新和科技创新,推行了一系列有利于研究生综合素质和培养质量提高的有效措施,建立了研究生创新培养机制,取得了一定的成绩。     

Portfolio learning for foundation doctors: early feedback on its use in the clinical workplace

CONTEXT: A learning portfolio was developed to support the development of trainee doctors piloting Foundation Programme prototypes across the Northern Deanery in 2004 and 2005. Trainee doctors and their educational supervisors were surveyed about their experiences of using the portfolio in the clinical workplace. METHODS: The evaluation consisted of semi-structured interviews with trainee doctors and supervisors, followed by postal questionnaire surveys in 2004 and 2005. Quantitative and qualitative data were triangulated to identify core findings. RESULTS: Questionnaires were returned from 182/305 (60%) trainee doctors and 104 out of 179 (58%) educational supervisors. The portfolio was felt to be a 'good idea' by 55% supervisors and 48% trainees. Trainees' perceptions of the educational value of the portfolio remained consistently low over 2 surveys and they described a sense of 'burden', whereby they identified problems in workload and usability and in gaining feedback on performance. However, positive trainee attitudes towards the portfolio were significantly correlated with greater perceived educational benefits (r = 0.855, P < 0.001). DISCUSSION: Learning portfolios are now an integral part of Foundation Programme training but this evaluation suggests that many trainee doctors and educational supervisors are yet to be convinced of their educational value. Gaining multi-source feedback, a substantial component of trainee doctors' portfolios, impacts on the wider clinical team and presents a significant challenge to trainees. Educational supervisors continued to rely on feedback from clinical colleagues, rather than portfolio evidence, to monitor trainee doctors' development. Such factors may serve to disengage trainees with the portfolio process by overshadowing any perceived educational gains.