Letters to the Editor

Evaluation of teaching – Paper versus electronic methods

Dear Sir

Teaching sessions for junior doctors are commonly evaluated using a paper questionnaire handed to participants at the end of the session. More recently evaluation has been undertaken on-line, often several days later. It is not known if the delay and changed modality affects the content of the evaluation.

We have compared the results of evaluations using both methods for the same teaching. Sixty-eight F2 trainees attended a seminar entitled ‘Clinical Governance and Patient Safety’ (delivered by RP). Trainees were expected to complete an on-line evaluation within 2 weeks of the seminar date. However, they were also asked to complete an identical paper-based questionnaire at the end of the session.

They were asked to mark both the content and delivery as ‘poor’, ‘average’ or ‘good’. There was space for comments. It was possible to calculate a percentage score by allocating a mark of 1 for ‘poor’, 2 for ‘average’ and 3 for ‘good’; the sum of these scores was divided by the maximum score available (3 × the number of returns) × 100.

There were 55 paper and 68 on-line responses. The paper scores were 95% for content and 96% for delivery; the on-line scores were lower at 85% for content and 87% for delivery. The number of comments made per person was higher for the paper evaluation (1.7) than the on-line (1.0). The percentages of positive, neutral and negative comments (most were positive) were similar for the two methods.

This study has shown that a presenter receives more favourable and extensive feed-back if the evaluation is requested shortly after an educational session, compared with an evaluation several days later on-line. Immediate responses may reveal feelings of well-being and the degree of rapport with the teacher rather than educational value of the teaching itself.

However, the differences could also reflect the physical nature of paper and on-line methods; the effort required to log on to the internet, use passwords and type responses may have a negative impact. This takes longer than the completion of a paper questionnaire and may explain the reduced number of comments. There were more on-line than paper returns because the former was obligatory and the latter voluntary.

Multiple factors should be taken into account when interpreting the results of evaluations.

Robert Palmer

Heart of England NHS Foundation Trust

Birmingham, UK

E-mail: [email protected]

Veronica Wilkie

Warwick Medical School

Warwick University

Coventry, UK

Empathy among medical school applicants

Dear Sir

It has been suggested that those who enter the medical profession begin indoctrination with an empathy deficit (Hojat et al. 2004). Investigators have reported negative changes in resident mood and empathy, cynicism, and burnout (Thomas 2004), but have only begun to examine these changes in medical students. Importantly, medical school admissions serve as a critical gate-keeping step in the doctor-building process. Therefore, selecting optimal medical students endowed with utmost empathy is crucial to the future of physician practice. We sought to investigate the association between empathy and time between undergraduate college education and medical school matriculation as an area yet unexamined. Intentionally or not, pre-medical education dogma encourages immediate matriculation to medical school. Medical school is unique in that the majority of matriculants come directly from college with minimal time between the two institutions. The average age of medical school applicants is 24, compared to the average business school applicant's age of 27 years. We surveyed 127 first-year medical students completing the Interpersonal Reactivity Index (IRI) and the Jefferson Scale of Physician Empathy (JSPE) on the first day of the class of the first year of medical school. Sub-scales of the IRI most relevant to physician empathy (Empathic Concern and Perspective Taking) were analyzed separately, while the JSPE was reported as a summed score. Scales were analyzed in a multiple linear regression against sex, undergraduate college major, and time between college and medical school. On the IRI empathic concern sub-scale, students showed a significant gain in empathy with each year before medical school (regression coefficient 0.46 [95% CI 0.09–0.82]). Though not statistically significant, mean scores on both the IRI perspective-taking subscale and the total JPSE scale demonstrated a similar trend (0.42 [95% CI –0.03, 0.88] and 0.45 [95% CI –0.50, 1.39], respectively. The finding of this preliminary study suggests a positive correlation between the amount of time students delay matriculation to medical school and increasing empathy. The age difference itself may be independently responsible for the discrepancy in empathy as this group may possess greater emotional maturity. Alternatively, a break in between college and medical school may help prevent burnout due to providing a recovery period free from competitive academic demands. Furthermore, recent undergraduates may still be under the ‘survivalship’ mentality of premedical preparation, which encourages selfishness resulting in decreased empathy and compassion. Future research should investigate the implications this correlation has on medical professionalism and potential admission policies.

B. Gabriel Smolarz

Division of Endocrinology, Diabetes, & Metabolism

University of Pennsylvania

Perelman Center for Advanced Medicine

Philadelphia, PA 19104, USA

E-mail: [email protected]

Afton Hassett

Department of Rheumatology

UMDNJ Robert Wood Johnson Medical School

New Brunswick, NJ, USA

Steven Buyske

Department of Statistics & Biostatistics

Rutgers University

Piscataway, NJ, USA

Correlation of attendance pattern with academic performance of medical undergraduates in pediatrics

Dear Sir

In the background of a declining trend of attendance in lecture classes globally despite strategies to improve the same (Mueller et al. 2008), a study was conducted to determine the pattern of attendance at lecture and practical classes of medical students in Pediatrics and its bearing on scholastic performance.

Attendance in both theory and clinics of 64 students was monitored through the three clinical years of the MBBS course. The students were periodically evaluated prior to summative evaluation. The attendance was correlated with scholastic performance for the whole batch as well as the top and bottom 10 students.

For the batch as a whole, the marks in theory and clinics were higher in those with better attendance although it was not statistically significant [r = 0.481 (theory); r = 0.482 (clinics)]. However, for the top and bottom 10 students this difference was significant [r = 0.642 (theory); r = 0.627 (clinics)]. Mean attendance of the top and bottom 10 in theory was 93% and 77.4%, respectively (p = 0.001858). In clinics it was 96.3% and 78.9% (p = 0.001863). Good performers maintained satisfactory attendance in all the 3 years, both in theory and clinics. Poor performers showed high attendance in theory in the first year and a declining trend in the final year, while the reverse was seen in clinics.

Good students are regular in all forms of teaching learning activities. Poor students, on the other hand, have a policy of strategic learning. As they progress in the course they seem to find theory classes less useful, whereas need for acquiring clinical skills improves attendance in clinics. It has been noted that class attendance influences examination results (Khan et al. 2008). Since medical profession requires not only clinical skills but also the application of theoretical knowledge to clinical situations, attention needs to be focussed on making theory classes relevant and interesting.

Shanthi Ananthakrishnan

Dhandapanny Gunasekaran

Mahatma Gandhi Medical College and Research Institute

Puducherry – 607402, India

E-mail: [email protected]

Ann Gaunt

Admissions Administrator

Leeds Institute of Medical Education (LIME)

Is Wikipedia unsuitable as a clinical information resource for medical students?

Dear Sir

Guiding students’ use of clinical information resources is an important role of a medical program, given the need to establish information literacy, evidence-based practice and lifelong learning habits amongst medical students. Observations that students were citing Wikipedia and concerns about the Google generation's information handling prompted us to compare this source with long-standing information resources (Joint Information Systems Committee (JISC) 2008).

We compared the entries on conjunctivitis, multiple sclerosis and otitis media in Wikipedia along with the free version of eMedicine (http://www.emedicine.com/) and two subscription resources, AccessMedicine (http://www.accessmedicine.com/home.aspx) and UpToDate (http://www.uptodate.com/home/index.html). Three experts compared the four resource entries focusing on one topic each. The labour on each topic was intensive (total ∼20 h), thus restricting our study to three topics. Experts were blinded to the sources by removing all identifying resource brands and titles. Each expert used the same rating scale for ranking content, based on: accuracy; coverage; concision; currency and overall suitability for providing a foundation of learning for the practice of medicine. Two medical librarians assessed the accessibility and usability of the resources by examining: cost and login requirements; ease of finding and navigating the information and the quality of presentation.

The entries in Wikipedia, in comparison with the other resources, were easy to access, navigate and well presented. Although reasonably concise and current, the Wikipedia entries failed to cover key aspects of two of the topics, and contained some factual errors. Wikipedia was judged unsuitable for medical students.

Traditional information resources would be improved by having in-text referencing to strengthen the link to evidence. With the emergence of Medpedia, what is hoped to be the world's largest online medical encyclopaedia (Medpedia 2009; http://www.medpedia.com/), it is recommended that experts contribute to such resources to ensure the provision of best health information and to avoid excessive costs of commercial alternatives.

Michael P. Pender

Royal Brisbane and Women's Hospital

The University of Queensland

Brisbane, QLD, Australia

Kaye E. Lasserre

The University of Queensland Library

Brisbane, QLD, Australia

Christopher Del Mar & Lisa Kruesi

Faculty of Health Sciences

Bond University

Gold Coast, DC, QLD, Australia

The University of Queensland Library

Brisbane, QLD, Australia

E-mail: [email protected]

Satyamurthy Anuradha

School of Population Health

The University of Queensland

Brisbane, QLD, Australia

The need for education in ultrasonography

Dear Sir

The use of ultrasonography has grown significantly in recent years. The safety, low-cost and non-invasiveness of the technology allows it to be utilized in virtually all patients, providing rapid diagnostics right at the bedside. At present, ultrasound comprises nearly 25% of all the imaging studies performed around the world, and sales are expected to grow into billions of dollars over the next 10 years (Reardon et al. 2006). Moreover, in the pursuit of increased patient safety, ultrasound is quickly becoming the standard of care in a variety of procedures. For example, the Agency for Healthcare Research and Quality lists ‘use of real-time ultrasound to place central venous lines’ as one of its core safety measures (Shojania et al. 2001).

Numerous studies have shown that medical professionals, from students to experienced physicians, often miss clinically important findings on physical examination. In contrast, studies have also shown that these same groups can acquire and interpret clinically significant findings using ultrasonography, including AAA, LVH, valvular disease and pleural effusion. Despite this, standards for ultrasound training vary across specialties and are non-existent for medical students and internal medicine residents. The ACGME requires that internal medicine residencies have facilities available for ultrasonography; however, no mention is made of formal training requirements. Similarly, the AAMC's report on clinical skills curricula includes abdominal and pelvic ultrasound interpretation in its list of recommendations, but no additional guidelines are provided.

In our survey, comprising 163 medical students and 40 senior internal medicine residents, both groups reported low competence in ultrasonography (rated as 2.58 on a Likert-type scale, with 3 indicating a neutral response). Furthermore, competence did not increase significantly between students and residents – this suggests that the ‘on-the-job’ ultrasonography training that students and residents currently receive is lacking. Despite this, or perhaps because of it, the participants in our study had a keen interest in further ultrasonography training (rated 4.22/5.0), and over 99% of the participants felt that ultrasonography knowledge and training are useful to physicians. Ultrasonography may one day be as pervasive as the stethoscope – it is imperative that medical educators prepare students and future internists accordingly.

Chad Kessler

Emergency Medicine JBVA Hospital

Chicago, IL, USA

E-mail: [email protected]

Stephen Bhandarkar

University of Illinois at Chicago

Chicago, IL, USA

Designing international health electives using the CanMEDS core competencies

Dear Sir

Globalization has opened the doors for medical trainees to undertake international medical electives, mostly in developing countries. International Health Electives (IHEs) provide a means to gain a broader exposure to other countries’ cultures, medical challenges, and health care systems, while increasing the opportunity to improve clinical skills, knowledge, and attitude. IHEs further provide a broader outlook on the geopolitical and social aspects of humanity, which include idealism, community service, humanism, and an interest in serving under-serviced populations.

While post-graduate electives tend to have more structured learning objectives and mentors who are attuned to trainee needs, medical student experiences are often less rigorous. Undergraduate medical electives need to be well structured to meet predefined outcomes that optimize students’ experience, but there are limitations to what can be achieved based on location, training needs and local resources.

We developed a unique undergraduate International Pediatric Emergency Medicine Elective (IPEME) using the CanMEDS framework of competencies (Frank 2005). IPEME is a 4-week elective bringing together eight medical students equally represented from Canada, Israel, Jordan, and Palestine. An educational plan was created to ensure that students were exposed to the three main foci of the elective: pediatric emergency medicine, global health, and research methodology. Sessions were designed to introduce participants to the subject matter within the context of an overall global health theme. Practical workshops were stressed to facilitate student interactions.

The entire program utilized the CanMEDS roles in several areas, with many of the sessions having cross-competency outcomes which ensured a rich and fruitful outcome. For example, the primer session on resuscitation was a half-day workshop where the students practiced effective CPR, worked as teams in running a code, learned the skills of orotracheal intubation, and the ethics related to the termination of resuscitation. The content related to cardiorespiratory arrest provided the medical expert domain, running codes as teams provided collaboration and communication, and issues related to the termination of resuscitation provided a glimpse into the patient advocate realm.

There have been no descriptions or studies that have looked specifically at the role of CanMEDS in undergraduate IHEs, and this program can provide a template for developing such programs. Given the dearth of structured learning outcomes in many undergraduate international electives, this unique program provided one means of improving the educational outcomes of medical students undertaking IHEs.

Rahim Valani

Sunnybrook Health Sciences Centre

University of Toronto

2075 Bayview Avenue

Toronto, ON M4N 3M5, Canada

E-mail: [email protected]

Abi Sriharan

Mount Sinai Hospital

Toronto, ON

Canada

Dennis Scolnik

Department of Pediatric Emergency Medicine,

Hospital for Sick Children

Toronto, ON, Canada

Establishing a conference for a small program

Dear Sir

Residents in small training programs often lack the opportunity for networking with other residents. Similarly, teaching in their specialty is often given in small groups which may limit extensive discussion. As well, the Royal College of Physicians and Surgeons of Canada (RCPSC) utilizes the CanMEDS roles to guide medical education (RCPSC-CanMEDS 2009). CanMEDS focuses on articulating a comprehensive definition of the competencies needed for medical education and practice, and is organized around seven roles (medical expert, professional, scholar, health advocate, manager, collaborator and communicator) (RCPSC-CanMEDS 2009). Training programs that have a small number of trainees often find that teaching of the non-medical expert CanMEDS roles is difficult. In addition, both the RCPSC and the American Society of Pediatric Hematology Oncology (ASPHO) Training Committee require training in communication, collaboration, professionalism, and advocacy, and mandate research as a requirement of all training programs (Hastings et al. 2007; RCPSC-CanMEDS 2009).

In 2006, an inaugural conference for Canadian Pediatric Hematology/Oncology Program Directors and Residents was held. During the conference, all residents had the opportunity to present their research projects and feedback was given. Topics covering all of the CanMEDS roles were presented. As well, specific sessions were held on thriving in residency and reflective practice in medicine. There was also time dedicated for the residents to meet as a group with a facilitator and without their program directors present. Anonymous feedback from this session was given to the program directors which they later discussed amongst themselves to address any concerns raised.

There were 23 participants in the inaugural conference and it had an overall rating of 4.79 on a scale of 1 (weakest) to 5 (strongest). The overwhelming response from attendees was that they benefited from opportunities to interact and discuss training experiences with other residents and program directors. The second conference had 35 participants and had an overall rating of 4.56. Comments revealed that the participants especially appreciated the chance to meet with colleagues in a more relaxed setting, and the opportunity for networking.

Overall, a small conference at a location that fosters a relaxed and collegial atmosphere provides useful opportunities for collaboration, communication, and networking among all involved in the training process of a subspecialty. As well, a conference of this format this provides an excellent forum for the teaching of non-medical expert roles that are a necessary part of all training programs.

Donna L. Johnston

Division of Hematology/Oncology

Children's Hospital of Eastern Ontario

Ottawa, ON, Canada

E-mail: [email protected]

David Dix

Division of Oncology, BC Children's Hospital

Vancouver, BC, Canada

Ronald Anderson

Division of Hematology/Oncology

Alberta Children's Hospital

Calgary, AB, Canada

Student perceptions of the influence of visual imagery in medical school application prospectuses in the UK

Dear Sir

A recent study of visual images in the application prospectuses of all the UK medical schools noted the possible influence of these images on the decision of prospective students to apply to medical school (Chowdhury et al. 2009). We sent a semi-structured questionnaire to all applicants who applied to one UK medical school until we had obtained 300 fully completed questionnaires. We found that 14 (4.7%) of the applicants stated that they were ‘to a great extent’ and 105 (35.0%) ‘to some extent’ influenced by the choice of visual images in the application prospectus. We were surprised by several comments about the images allowing applicants to vividly imagine themselves as future students engaged in learning at the chosen medical school. The importance of the portrayal of a friendly teaching and learning atmosphere, such as students smiling and looking happy, was also noted by several applicants, as was modern and high-quality teaching facilities. In contrast, the 60.3% (181) who stated that they were ‘to a little extent’ or ‘to no extent’ influenced by the images in the application prospectus made comments about the curriculum and the quality of teaching as factors that influenced their choice of the medical school.

Our study highlights the importance of ‘gut feelings’ in making a decision to apply to a particular medical school. This phenomenon has been noted in the application decision-making process for other disciplines (Symes 1998), but not previously for medical schools. The importance of our findings is that medical schools need to ensure that the applicant's mental picture will be congruent with their actual student experience, otherwise students may become disenchanted and leave prematurely.

John Sandars

Medical Education Unit

The University of Leeds

20 Hyde Terrace

Leeds LS2 9LN, UK

E-mail: [email protected]

Ann Gaunt

Admissions Administrator

Leeds Institute of Medical Education (LIME)