LETTERS TO THE EDITOR

Medical education, confidentiality, informed consent and the net generation

Dear Sir

The internet is an important learning tool for students of the ‘Net Generation’ (Sandars & Morrison 2007). These students have grown up using computer based learning environments. It has recently been suggested that watching video clips via eLearning facilitates learning (Romanov & Nevgi 2007). Recent opinion pieces have suggested that the ‘new media’ of wikis, blogs, blikis and sites such as YouTube are the future of medical journals (Hutchison 2007; Tilstone 2007).

To survey the medical educational content of the popular online video sharing site YouTube (www.youtube.com) we performed a search reflecting the author's preferences for subjects in undergraduate medical education. We searched (30/11/07) using the terms ‘Radiology’, Human anatomy, ‘Orthopaedics’ and ‘Clinical examination’. Human anatomy yielded 682 hits the majority of which contained relevant information (589, 86%), consisting of lectures, dissection, descriptions of anatomical models and computer reconstructions. Of interest was the large number videos dedicated to drawing the human form. A number of videos were retrieved under this search term which recorded intimate physical examinations.

Clinical examination as a search term yielded 137, the majority of which were relevant (101, 73%). A number of professionally made videos were present especially those concerning cranial nerve examination. Radiology yielded fewer relevant videos which is surprising considering the computer based technology used in this specialty (42/297, 14%). These videos consisted of lectures, tutorials and procedures. Orthopaedics produced 525 videos with 59 being judged relevant for learning (11%) consisting of lectures and operations.

These results were surprising and raised a number of important issues. Firstly we would welcome the open and free distribution in the public domain of information which may promote health awareness for example descriptions of inhaler technique. In addition, several of the videos appear produced by students who have taken control of their own learning particularly in Anatomy, which is to be commended. Undoubtedly YouTube is changing and challenging medical education.

Despite this several worrying facts emerge. The standard of the video learning aids on YouTube is variable, it seems unlikely they will replace formal organised teaching and there is a potential to mislead. There appears to be little consistency between the search terms used and the content of the videos retrieved. The intimate nature of the videos made available on YouTube came as a surprise to the authors who had not expected to find examples of vaginal examination, rectal examination, male genital examination, breast examination and guidance on how to perform a Pap smear freely available.

Judging from the age of the videos, and in some cases the medical conditions displayed, it seems unlikely that informed consent to post such material on the net has been obtained. Furthermore informed consent, patient confidentiality and the potential complexities arising from such issues are not addressed in any depth.

Andrew Wood

[email protected]

Barry Traill

[email protected]

Bute Medical Building

University of St Andrews

St Andrews, UK

What access and use of Internet technology for undergraduate medical students?

Dear Sir

It is becoming a universally acknowledged truth that the education of undergraduate medical students will be enhanced through the use of computer-assisted learning (Ward et al. 2001). New learning environments such as distance education and computer-aided instruction bring a change in learning environment by adjusting the relationship between the learner, the educational content and the organization of education (Masiello et al. 2005). So we assessed Internet and computer availability, use and attitude towards using ICT in the curriculum of undergraduate medical students in the Medical School of Rouen (France).

Our study was conducted in three successive cohorts of third years of medical students between 2004 and 2006. The following data were collected: first, demographic data (age, sex); secondly, computer and available Internet resources, the use of Internet, an e-mail address and a high speed Internet access; thirdly, estimation time of connection per week to Internet and specially to teaching resources research (TRR); finally, opinion of Internet usefulness for curriculum (high, moderate, weak and no usefulness), Internet skills (scored/4): ‘do you know how to use a search engine, use of favourites list, attach a file by e-mail and send a link by e-mail’.

A total of 347 students were included in the survey (107 in 2004, 121 in 2005 and 119 students in 2006). The mean age was 20.4 years and the sex ratio M : F was 0.48. 95.7% had a computer at home and use Internet. 72.1% had a high speed Internet access with an increase of 50.5% to 82.1% between 2004 and 2006 (p_trend < 10⁻³) and 89.9% had an e-mail address (84.1% in 2004 and 94.1% in 2006; p_trend < 10⁻³). A third of time of Internet connexion was used to TRR (31% in 2004, 28% in 2005, 31% in 2006; p_trend = 0.72). The opinion of high usefulness Internet for curriculum improved between 2004 and 2006 (28,9% to 42,0%; p = 0.007). Score skills was 2.8 in 2004 and 3.3 in 2006 (p < 10⁻³).

During the three years of this study conducted in France, Internet has become a common tool used by medical students, in particular to consult and search pedagogic resources online. Management by teachers is necessary to guide students and optimize their availability to critically analyse pedagogic resources. Teachers and courses directors should consider this recent evolution as an opportunity to improve student capabilities and efficiency and to embrace this new technology.

Marie-Pierre Tavolacci, Cédric Laouenan, Joël Ladner

Département d'Epidémiologie et de Santé Publique

Centre Hospitalier Universitaire – Hôpital Charles Nicolle

1, rue de Germont. 76031 Rouen-cedex. France

Phone: [phone] Fax: [phone]

E-Mail: [email protected]

Case based discussion with U.K. Foundation Trainees – Will outcomes match expectations?

Dear Sir

Case based discussion (CbD) is a new teaching/assessment tool for Foundation trainees (junior doctors in their first two years post-qualification). It uses a discussion based on the clinical records to assess areas such as professional judgement. The Modernising Medical Careers (MMC) National Guidance's stated aim for the tool is a ‘systematic assessment’ – but (paradoxically) the assessment should also be ‘mainly developmental’ (MMC 2006). The assessment ‘scores’ are central to Healthcare Assessment and Training board (HcAT) summative assessment of Foundation doctors. However, the pass score 4 – ‘meets expectations for Foundation completion’ – is a subjective rating. Thus the assessment quality rests on the judgment and performance of the assessor.

Training for most CbD assessors consists of written guidance and an online ‘demonstration’ video, possibly (but not compulsorily) accompanied by a workshop where scoring can be benchmarked with colleagues. Despite the stated formative aims of the tool, the video demonstrator pays scant attention to process or consequential validity. He demonstrates limited skills in giving feedback. Where the trainee mentions she wants to be sure she performed adequately, the supervisor attempts to reassure her without checking if this feedback meets the need or triggers any development. There is little evidence of formative outcome.

The tool's validity may be compromised by forbidding repeat assessments from one assessor. A ‘one off’ assessor might collude with the learner and sign off a borderline assessment without reference to previous performance or context. Gathering information for triangulation and repeat assessments over time from one individual would help overcome this limitation. It would be preferable if the patient case chosen was personally known to the assessor, to allow evaluation of any discrepancy between the information recorded by the junior doctor in the records and the reality of the clinical scenario.

Quality assurance of assessor performance is currently inadequate. In the absence of any formal mechanism for evaluation and feedback on performance it is difficult to see how assessors with substandard skills will be detected and given the opportunity to improve. For the tool to be reliable, a formal ongoing programme of assessor competence review is required, ideally using trainee feedback coupled with direct observation (or videoing). The National Guidance's lack of recommendations on quality assuring assessor performance requires urgent rectification.

Dr. Cath Jenson

Foundation Director

Queen Mary's Sidcup NHS Trust

Frognal Education Centre

Frognal Avenue

Sidcup

Kent

DA14 6LT United Kingdom

Tel: [phone]

Email: [email protected]

A students' perspective of how to pass clinical finals

Dear Sir

Having successfully completed clinical finals only last month, I feel that it's important to share some of the unknown and unsung reasons why students pass and which specific areas teachers sometimes neglect.

At St George's, we are fortunate enough to have formal OSCE assessments throughout the course and so when finals approach students are well versed as to what an OSCE involves. Critically though there are no mock assessments in the weeks prior to clinical finals. In my experience mock exams are an invaluable tool for the student who can gauge areas of weakness and hone exam technique. For the examiner it provides an ideal opportunity to clarify mark sheets and offer formal training for newly appointed examiners.

Revising regularly with a group of students is of paramount importance. Practising examinations, histories and explanations amongst a group of three students on a daily basis can be painfully tedious but is probably the single most important aspect to passing the clinicals. Revising by oneself for the clinical exams reinforces bad habits and ensures that students may not cover all the necessary material. Group study cannot be over emphasised by teachers at an early stage.

There is no substitute to examining patients regularly during clinical training. Examining patients from the third year is a priceless aide memoir and breaks any taboos students may have developed. I believe teachers at all levels need to encourage students to examine more patients and make more patients available for formal teaching sessions.

Before finals there are numerous medical companies offering “courses tailor made for students guaranteeing exam success.” I naively attended a few of these courses and thought like most students that not attending would guarantee exam failure. The courses tend to run over the weekend and require a massive financial investment and take up precious time otherwise spent in group study. They rely heavily on assuming the student has prior knowledge of the subject and can complicate existing principles.

Revising for clinical finals in a group can as already mentioned be mind numbingly dull as the constant repetition can take its toll. To reach this point though means that the student has mastered a particular skill and so in the exam would be able to repeat it by second nature. I revised with my two housemates and during the weeks preceding finals our friendship grew into a real camaraderie. The three of us were desperate for each other to excel in the exams and so we pushed each other along, learning from our collective mistakes and teaching each other new techniques we had picked up over our clinical training. Clinical finals were the most physically and mentally demanding of all the undergraduate exams and the kinship provided by my study group can’t be underestimated. I believe that group study has helped me realise the importance of team work and prepared me better for work as a junior doctor. The old adage that “practise makes perfect” certainly holds true to passing clinical finals.

Seilesh Kadambari

St George's Hospital Medical School

Blackshaw Road

London SW12 0QT, UK

Email: [email protected]