Sandwich联合案例教学法在神经内科临床实习中的应用

目的 探讨Sandwich联合以案例为基础的教学法在神经内科临床实习中的应用效果,为进一步优化教学方法提供参考.方法 以98名神经内科实习护理本科生为对象,按照实习病区分为对照组与观察组各49名.对照组采用传统教学法进行教学,观察组在对照组基础上采用Sandwich联合以案例为基础的教学法.出科前比较两组理论考试成绩及对教学方法的评价.结果 观察组理论考试成绩及教学满意评分显著高于对照组(P＜0.05,P＜0.01).结论 Sandwich联合以案例为基础的教学法可有促进学生对理论知识的掌握,提高教学效果.     

The teaching of medicine at the University Centre for Health Sciences Yaounde,Cameroon: its concordance with the Edinburgh Declaration on Medical Education

Summary. The University Centre for Health Sciences (UCHS) or as it is referred to in French ‘Centre Universitaire des Sciences de la Santé’ (CUSS), became functional in 1969 with the enrolment of the first group of students. The objective of this training programme was to produce a scientifically sound, multipurpose doctor who would be fully operational in a rural setting with minimal equipment and supplies ( Monekosso 1970, 1972 ). The graduate had to be able to adapt readily to new situations and improvise whenever possible, calling for a high degree of competence and initiative. The training strategies adopted by UCHS in 1969 which met this requirement were later found to be in close concordance with the tenets of the World Conference on Medical Education held in Edinburgh in 1988, the Edinburgh Declaration. While some of the terminology may not have been worked out at the time, the programme developed embraced some new concepts hitherto untried or undeveloped:

• — the problem-solving approach in the first to the sixth year;
• — an integrated teaching approach during the first to sixth year of medical training;
• — an integrated medicine internship in district hospitals in the sixth year;
• — a community-based training approach throughout the training;
• — team training of three different health professionals;
• — competency-based training;
• — health services linked research;
• — health services linked training ( Monekosso & Quenum 1978 ).

The concordance of this programme to the Edinburgh Declaration is of great interest in realizing the World Federation for Medical Education programme and implementing the Edinburgh Declaration. The involvement of the three innovative medical schools in the planning stage of the curriculum explains this concordance.     

The impact of student-generated learning issues on individual study time and academic achievement

OBJECTIVES: The aim of this study was twofold. The first question concerns the way students make use of the learning issues they generate (as strict guidelines or as global guidelines) and whether this changes across years of training. The second question concerned the relationship between the way students make use of learning issues and the time spent on individual study and achievement on two tests of knowledge. DESIGN: A questionnaire was developed, containing seven items that measured to what extent students study strictly according to the student-generated learning issues and six items that measured to what extent students study beyond the student-generated learning issues. The questionnaire also contained one question in which students had to estimate the mean time spent on individual study. Achievement was measured by two forms of tests of knowledge, a block test assessing course content and a progress test assessing long-term functional knowledge. SETTING: Medical School of Maastricht University, the Netherlands. SUBJECTS: Medical students (response=69%) from the problem-based curriculum at the Maastricht University. RESULTS: During their first year students study strictly according to the content of the learning issues, whereas in later years students studied more according to their own learning needs and interests. In addition, students who tended to study beyond the generated learning issues spent more time on individual study and achieved better on both tests. CONCLUSIONS: Students in a problem-based curriculum seem to become better self-directed learners during the years of training.     

Medical students in ENT outpatient clinics: appointment times, patient satisfaction and student satisfaction

OBJECTIVES: Outpatient clinics are increasingly important in medical education. The effect of students on clinic times and patient satisfaction, as well as their own satisfaction, were studied. DESIGN: A prospective, non-randomized, controlled study using adult patient questionnaires, medical student questionnaires and clinic time sheets. SETTING: Two teaching hospital ENT clinics. SUBJECTS: Medical students and adult patients. RESULTS: Three hundred and twenty-five patient questionnaires were collected (77% response), including 135 student encounters. Students did not affect appointment durations (19 min +/- 0.48 (standard error)) except at centre B (35 min +/- 1.1, P < 0.0001) where patient numbers were cut for teaching. Patient satisfaction, generally high, was not affected by students, appointment duration or gender of doctor or patient. It was slightly higher in the lower social classes (rs = 0.20, P = 0. 003) and older patients (rs = 0.17, P = 0.002). Student acceptability scores were not affected by student numbers (up to four), social class or time spent alone with students. They were higher if time was spent alone with the doctor (75.3% +/- 4.9) than not (63.0% +/- 1.8, P = 0.024). Thirty-six per cent of patients preferred to have a student present; only 9% preferred not. Student satisfaction was higher at centre B (73.7% +/- 2.3) where appointments were longer and students spent more time alone with patients than centre A (64.3% +/- 2.3, P = 0.0052). CONCLUSIONS: Clinic appointments are not necessarily longer in the presence of students. When students have the chance to see patients alone during longer consultations, student satisfaction is higher. Patient satisfaction, generally high, is not altered by the presence of students, but patients given time alone with their doctor are more accepting of students. These findings have resource implications for the planning of NHS clinics in teaching hospitals.     

Students conducting consultations in general practice and the acceptability to patients

OBJECTIVES: The General Medical Council has recommended that medical students should gain more experience in general practice. The study set out to determine patients' reactions to consultations conducted by a medical student alone prior to seeing their GP. DESIGN: A random sample of patients attending general practice surgeries in the Oxford area completed a questionnaire following consultation with a medical student. SETTING: Six general practice teaching surgeries. SUBJECTS: Fifth-year medical students. RESULTS: Of 130 responders 98% experienced no disadvantage in seeing the student; 35% considered that there were advantages in seeing the student; 98% said that they would be prepared to consult with a student again; 85% expressed no concerns about the gender of the student. CONCLUSIONS: The results of this study are very reassuring concerning the acceptability to patients of consulting with medical students and are more favourable than those reported for studies of students being present in consultations by GPs.     

Single-handed practices – their contribution to an undergraduate teaching network in the first year of the new curriculum

OBJECTIVES: The new curriculum at King's College School of Medicine and Dentistry, which commenced in September 1996, requires all medical undergraduates to have a general practice placement throughout the 5 years of their medical education. DESIGN: This paper discusses recruitment, training and support of teaching practices for the new curriculum, reviews the distribution of single-handed general practices in the network and, via a selection of monitoring and evaluation procedures, discusses the implications of a policy which is inclusive of single-handed practices. The findings relate to the experience of the first semester of the first year of the new curriculum. It also examines the contributions that single-handed practices have made to the teaching network and the kind of support needed, if single-handed practices are to continue to contribute to the King's teaching network. SETTING: King's College School of Medicine and Dentistry. SUBJECTS: Medical undergraduates. RESULTS: The findings of this paper revealed that over a third of general practice provision is via single-handed practices in South-east London. Within the undergraduate teaching network, 10% of practices are single-handed. Students are welcomed and receive a learning experience comparable to those students in larger practices. Attendance at training events has proved difficult for some of these tutors, but the extra input from the department, in order to address this deficit, has not been onerous. Indeed, single-handed practices have not been unique with regard to difficulties in attendance at training events. CONCLUSIONS: The study concludes that single-handed practices can make satisfactory provision for undergraduates in the new curriculum and there is no evidence from this study to suggest otherwise.     

Rape attitudes amongst British medical students

OBJECTIVES: To examine the rape attitudes of a sample of 252 British medical students. DESIGN: A 20-item questionnaire was used. SETTING: A London medical school. SUBJECTS: Fourth-year medical students. RESULTS: In general, students were well informed on legal and factual issues regarding rape and sexual assault. However, significant differences were found in the attitudes to rape between males and females. Female students were significantly more positive in their responses to victims. CONCLUSIONS: These results support findings from previous studies of rape attitudes in other professional groups. Better knowledge and enlightened attitudes amongst health care staff can have a significant impact on the management of sexual assault and influence the likelihood of victims presenting for treatment. In conclusion, this study emphasizes the importance of teaching about sexual violence in British medical schools.     

Evaluating problem-based learning in a multilingual student population

OBJECTIVES: The University of Natal Medical School in South Africa provides training for a student body composed of two groups: one with English as a first language and the other with an African language as a first language and English as the second. A new methodology was developed to evaluate an innovative course using modified problem-based learning techniques in this heterogeneous environment. DESIGN: The learning model proposed required achieving a balance of three components: content, enquiry/learning process and social interaction/group process. A multidimensional system, felt to be consistent with this educational philosophy, was developed using seven different quantitative and qualitative techniques. SETTING: The University of Natal Medical School. SUBJECTS: First-year multilingual medical students. RESULTS: The results revealed that social interaction was highly successful in reducing barriers between the student groups and between students and facilitators. However, the emphasis on group participation may have overshadowed the enquiry process, leading to superficial discussions of problems and feelings of repetitiveness. During the course students and facilitators expressed concern that the innovative assessments used did not assess the course content adequately. While the group presentations and projects were useful exercises for consolidation and group interaction, they did not enable facilitators to identify struggling students. CONCLUSIONS: The outcome of the evaluation stressed the need of achieving an appropriate balance both in the curriculum and assessments of the three components of the learning model, particularly in a setting where student backgrounds and language ability differ. Multidimensional methodology is needed for effective evaluation that promotes critical reflection.     

Difficulty and discrimination capacity of examinations estimated on the basis of repeated student failure

This paper examines the difficulty and discrimination capacity of several subjects for problematic students, i.e., those failing repeatedly (re-examined four or more times) in at least one subject. Four hundred and six problematic students were analysed. The difficulty in passing thirty-one mandatory subjects was assessed in two ways:

• 1 on the basis of the attrition rate of the students due to pass the subject,
• 2 on the basis of the percentage of number of failures over the number of examinations.

The discrimination capacity of the same subjects was assessed on the basis of ‘false positive’ and ‘false negative’ results. The result of the evaluation of one subject was considered a false positive if it gave an excellent mark to a problematic student; it was considered a false negative if a student had to be reexamined four or more times before passing, although he had at least one excellent passing mark in one or more subjects. There were 157 excellent marks given to 114 problematic students. The two ways to assess difficulty ranked the thirty-one subjects in a very significantly-similar way. The subjects of the first, second and sixth years of study were considerably more difficult than the other years. A high proportion of false-negative results in a subject did not imply necessarily increased difficulty and vice versa. Thus, only two of the five subjects with the highest proportion of false-negative results belonged to the group of the five most difficult subjects. Also, three of the five subjects with the highest proportion of false-positive results belonged to the group of the five easiest subjects. Finally, only one of the five subjects with the lowest proportion of false (positive plus negative) results belonged to the group of the five most difficult subjects. Examination systems involving oral examinations either alone or in conjunction with written ones were more difficult for the problematic students than those involving purely written examinations, while their discrimination capacity was not significantly different. The discrimination capacity of the subjects involving practical examinations as part of their evaluation system was significantly better than that of those not involving practical examinations. It is concluded that a very permissive examination system presents the problem of repeatedly-failing students. A quasi-open admission system, as in Athens University, associated with a very permissive examination system, leads to a pattern of difficulty, the peaks of which appear, mainly, in the first and last year of studies.     

A factor analytic study of teaching in off-campus general practice clerkships

The Preceptor-evaluation questionnaire (PEQ) was developed at the University of Mississippi Medical Center to evaluate the clinical teaching behaviour of general practice doctors in private practice who have one or more third-year medical students per year in their offices for a required general practice clerkship. The PEQ was designed to provide feedback to these doctors and the sponsoring department in an effort to improve teaching in this setting. Developed from the input of family practice doctors who have supervised students in their offices and from a review of related literature, the instrument was given to students to determine the level of importance they attributed to each teaching characteristic. A principle components factor analysis and subsequent varimax rotation produced six significant teaching factors in this setting. These six factors were:

• 1 demonstrates a humanistic orientation toward patients and staff;
• 2 demonstrates a humanistic orientation toward student;
• 3 provides opportunity for practice;
• 4 motivates and stimulates student's thinking;
• 5 communicates effectively with student; and
• 6 demonstrates comfort and confidence in the roles of doctor and teacher.

The factor relating to the humanistic orientation toward student has not appeared as a separate factor in other studies of clinical teaching. This may be due to the unique aspects of the relationship between student and doctor in this setting which may not occur in other settings. The PEQ and similar reliable and valid instruments can provide valuable information for the doctors in these off-campus teaching situations as well as provide useful programme planning information for the sponsoring academic departments. This information may also be valuable for off-campus residency training.