Letter to the Editors

An innovative model for the structured on-ward supervision of final year students

Dear Sir

Clerkships are generally viewed as a favourable learning environment for final year students. During this period, it is necessary to completely integrate final year students into ward procedures in order to improve their proficiency in independent patient management. Since on-ward supervision has been shown to be rare (Howley & Wilson 2004), we introduced an innovative model of a supplementary, structured, on-ward supervision for final year students, with experienced physicians who were not simultaneously the current ward physician serving as supervisors. Learning goals were defined based on a search of the literature (Schrauth et al. 2009) and comprised patient history taking and clinical examination, conducting ward rounds including chart documentation, the presentation of patient cases, and writing medical reports.

A cohort of final year students (n = 16; 9 female; mean age 25.0 years) agreed to participate in the on-ward supervision programme during their clinical rotation. Final-year-student supervisors (n = 2; 1 female) were third-year internal medicine residents and received intensive training in teaching methodology as well as in providing qualified feedback. Evaluation of the programme included post-intervention ratings on a seven-point Likert-scale ranging from 6 (very good) to 1 (unsatisfactory) and a focus group analysis.

Quantitative analysis revealed that final year students considered the programme to be extremely helpful (5.75; ±0.44), to improve their clinical skills (4.90; ±1.40), and to support independent working (4.80; ±1.01). They expressed the wish for the programme to be expanded (5.62; ±0.62). Final-year-student supervisors were seen as good teachers (5.81; ±0.40) that were sufficiently qualified (5.87; ±0.50) and were considered to represent an important attachment figure (5.80; ±0.30). A supplementary focus-group analysis based on a sub-sample of participants (n = 4) affirmed that delegated medical tasks normally remain unsupervised, and that final-year-students benefited enormously from the programme, mainly due to the close one-to-one monitoring by the supervisors.

In conclusion, an on-ward supervision programme is a feasible and well-accepted tool in final year medical education which assures supervision and conveys skills in independent patient management.

M. Eden

N. Köhl-Hackert

M. Krautter

J. Jünger

C. Nikendei

Department of General Internal and Psychosomatic Medicine

University of Heidelberg Medical Hospital

Im Neuenheimer Feld 410

69120 Heidelberg

Germany

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E-mail: [email protected]

Instruments for measuring quality of educational environments: Validation not required any longer?

Dear Sir

In his commentary in June 2009, Schuwirth questions ‘the truth’ about the internal structure of the PHEEM because several validation studies resulted in distinct outcomes. Considering the fact that so many studies all yielded different factor structures, he concludes that examining the scores on the individual items may add more to the value of the PHEEM than construct validation to determine its internal structure. In this letter, we would like to react to this statement.

The fact that a multitude of PHEEM validation studies all yielded different internal structures was precisely the reason why we performed our study (Schönrock-Adema et al. 2009). Contrary to Schuwirth, we do not believe that the inconsistencies represent differences between environments, but rather methodological differences in the approaches to factor analysis. Therefore, we recommend applying a number of psychometric criteria in combination with several interpretability criteria, rather than choosing one single criterion. It is not inconceivable that PHEEM validation studies yield more comparable outcomes if all researchers would apply the same thorough approach to factor analysis.

Schuwirth's conclusion that the 40-factor solution is most preferable almost sounds like a plea for not validating instruments. This is remarkable considering recent developments with respect to international standards for scientific publications. Currently, the use of theoretical and conceptual frameworks is emphasised increasingly as these are considered essential for achieving best practice and moving the educational research field forward (Prideaux & Bligh 2002; Eva & Lingard 2008; Bordage 2009). An advantage of a universal set of dimensions is that items of instruments do not need to be identical to permit comparisons across studies. An example may illustrate this assertion. Outside the borders of medical education, research yielded three dimensions each representing a different type of learning function: cognitive, affective and metacognitive learning functions (Shuell 1988; Vermunt 1996; Vermunt & Verloop 1999). Our validation of the PHEEM using the integrated factor analysis method yielded three dimensions congruent with the cognitive, affective and metacognitive domains of learning. Despite the fact that different instruments were used, comparable structures were found. Such a general structure enhances the comparison between studies and may offer a promising theoretical framework for further research. Therefore, we dare to assert that the value of conceptual structures exceeds that of individual items. In conclusion, we think that validating instruments will advance educational research and practice provided that psychometric and interpretability criteria are used for factor solutions.

Johanna Schönrock-Adema*

Janke Cohen-Schotanus

University of Groningen and University Medical Center Groningen

Center for Research and Innovation of Medical Education

A. Deusinglaan 1

Groningen

9713 AV

The Netherlands

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*E-mail: [email protected]

Medical students and recent graduates may disagree on the importance of procedural skills education

Dear Sir

We read with interest the recent publication by Fitch and colleagues investigating the instruction of procedural skills in medical school (Fitch et al. 2009). The question of which skills are necessary in the undergraduate medical curriculum is a central one in medical education, and one that is difficult to answer definitively. Several attempts have been made to define the skill set that an undifferentiated physician requires upon graduation from medical school. In this most recent study, the high proportion of skills in which graduates received limited or no hands-on training reflects an unfortunate reality that has been consistently demonstrated in the literature.

Our own study (Turner et al. 2007) found that even the eight skills listed as mandatory in the AAMC's Medical School Objectives Report were not taught by all medical schools. Our comparison between which skills medical students rated as important and those that were taught by medical schools revealed significant disagreement for a large number of skills. A significantly smaller proportion of schools taught chest tube insertion (53%), digital block anaesthesia (45%), central line insertion (63%) and other skills compared to the high proportion of students who thought they were important (94%, 75% and 90%, respectively). Interestingly, in contrast to the responses of recent graduates in the study by Fitch and colleagues, medical students in our study rated all 24 skills investigated as important.

That recent graduates rated several non-invasive skills as unimportant in this new study raises the question of whether there is a significant difference between the opinions of medical students and recent graduates with respect to skills teaching. Inevitably, further studies will elucidate this difference.

Simon R. Turner

Christopher J. de Gara

Department of Surgery

University of Alberta

Edmonton

Canada

T5J 1N3

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The use of reflective learning and online continuing professional development

Dear Sir

An essential aspect of continuing professional development (CPD) is reflective learning. There is also an increasing interest in the use of online CPD for healthcare professionals and some providers have started to offer online opportunities for users to reflect on their learning. BMJ Learning offers a wide variety of online modules which prompt users to voluntarily record their reflections on completion of each module. We were interested in the extent to which users reflected on their online learning.

We used anonymous routine website activity logs to identify the number of reflective comments made by a range of different healthcare professionals. We were surprised to find that 48.4% (3574: 7389) of general practitioners made a reflective comment and this was significantly greater than the number made by hospital consultants (40.2%, 1307: 3253), doctors in training (36.4%, 2280: 6254) and practice nurses (22.2%, 289: 1301).

We had expected that younger doctors would have made more reflective comments since reflective learning has recently become commonplace in structured training programmes and with the use of online portfolios. We also expected that practice nurses would have high rates since reflective learning is a well-established approach in nursing.

The reflective comments are only visible to other users of the module, with the intention that users will be stimulated to reflect, not only on their experience but also on that of other learners. An essential aspect of online participation, such as in discussion boards, is dependent on mutual trust and this may explain our findings (Preece 2000). It may be that doctors in training and practice nurses feel less confident in making comments about themselves in the presence of more senior colleagues or different professional groups.

Our findings have important implications and we recommend further research to understand how online reflective learning for CPD can be enhanced.

Kieran Walsh

Editor, BMJ Learning

London, WC1H 9JR, UK

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E-mail: [email protected]

Matthew Homer

Research Fellow, Assessment and Evaluation Unit

School of Education, University of Leeds

Leeds LS2 9JT, UK

John Sandars

Senior lecturer and academic lead for e-learning

Medical Education Unit

Leeds Institute of Medical Education

Leeds LS2 9LN, UK

Learning to maintain a ‘proper’ relationship with the pharmaceutical industry

Dear Sir

In Nepal, a developing country in South Asia, medical events and conferences are sponsored by the pharmaceutical industry. Pharmaceutical promotion is not commonly taught in medical schools. At the Manipal College of Medical Sciences, however, students are taught to critically evaluate drug promotion using role-plays (Shankar et al. 2006).

In KIST Medical College, the Medicine and Therapeutics Committee (MTC) has taken steps for promoting rational use of medicines (Shankar et al. 2009). The access of medical representatives (MRs) to doctors is regulated. MRs can only detail their medicines to doctors in groups, and gifts from the industry are not accepted. The pharmacology department conducts regular academic detailing sessions.

Undergraduate medical students learn the basic science subjects in an integrated organ system based manner during the first 2 years with early clinical contact. Students attend medical humanities and communication skills sessions every Wednesday morning in the hospital. Pharmacology is taught through didactic lectures and small group problem-based learning (PBL) sessions. During PBLs, students learn about pharmaceutical promotion and analyze drug advertisements and promotional material against the WHO ethical criteria of medicinal drug promotion. They verify and analyze the information supplied and claims made in the advertisements. Students learn about unethical promotion by MRs and issues involved in promotion through role-plays. Students learn to optimize time spent with a medical representative using group work, presentations and role-plays. The sessions are designed to develop students’ ability to critically analyze industry sources of information.

Aggressive promotion is not common in the hospital due to the measures of the MTC. Many senior clinicians are committed to the rational use of medicines and students have good role models to emulate. The issues of pharmaceutical promotion and the doctors’ primary responsibility toward the patient are also stressed during the medical humanities session. Informal feedback about these learning activities is positive. The challenge is to continue and develop these learning activities.

Shankar PR

Jha N

Bajracharya O

Piryani RM

KIST Medical College

PO Box 14142

Kathmandu

Nepal.

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E-mail: [email protected]

Teaching crisis intervention to medical students – When is the best timing?

Dear Sir

Physicians often need to convey bad news to patients, although research has shown that they find this difficult to do (Ptacek et al. 1999). Literature review has shown that there are many programs which teach residents how to convey bad news, but there are a negligible number of courses for medical students (Farber et al. 2002). We created a clinical workshop that teaches these skills to medical students. Students found this course very interesting and relevant, but we were not sure of the best timing for conducting this course – at the pre-clinical phase or at a more experienced phase closer to the end of their studies. So to answer this dilemma we gave in 2006 the workshop to 2nd and 6th year students and compared their expectations and attitudes toward the course.

The results were surprising – in most instances the differences were a feeling of greater competence in the 6th year medical students, even though they lacked any formal education in this area. An objective scale of measuring response to conveying bad news showed that 2nd year students were better. This difference showed a borderline significance (t = 1.91, p = 0.059) in an overall index of all questions, but individual questions showed quite a few in which this difference was significant.

What is a possible explanation of this paradox? And what can we learn from this? Well, the answer lies in a dichotomy once identified by our former dean, Prof. Glick, who taught us there are two kinds of medical students – those who are in the pre-cynical and those who are in the cynical phase, analogous to the pre-clinical and clinical phases in medical school. We believe that to some extent the more advanced medical students had a higher self-evaluation of their abilities, and that this over-confidence blocked them from being open to new ideas and training. Because they thought that they knew it all, their attitudes toward the course were less positive, and they were lacking the proper judgment used by 2nd year medical students who answered the objective part of our questionnaire more correctly.

Due to these results, we believe that the proper time to teach these skills is the pre-clinical phase of medical school, due to the more positive attitudes of younger students toward this course. We recommend if possible, a rehearsal of this educational program should be initiated to advanced years medical students, or junior residents.

Zvi H. Perry

Ziva Boussiba

Amir Rosenblatt

Aya Biderman

Gal Meiri

The Prywes Medical Education Center

Ben-Gurion University of the Negev

PO Box 653

Beer-Sheva 84105, Israel

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E-mail: [email protected]

Trainee written records: What's wrong? What's right? It depends!

Dear sir

Concise, accurate recording of clinical information using standardized formats is a core clinical skill expected of clerkship students (American Association of Medical Colleges 2008). In spite of its importance to patient care, the written record is sometimes left to the hidden, or informal, curriculum of medical schools and residencies (Donnelly 2005). The literature affords little guidance on the most efficacious strategy for helping trainees develop competence in writing either progress notes or complete history and physical examinations. Developmental differences, specialty-specific preferences, and the advent of the electronic medical record add frustration for both learner and teacher.

We wanted to gather information about the most frequent and important problems with trainee written records from three curricular vantage points: student graduate assistants, required clerkship directors, and residency directors. We hoped to better define faculty goals and expectations for trainees which could then inform necessary curricular and assessment changes.

A convenience sample representing three groups was obtained: third-year medical student graders of preclinical written record assignments (N = 5), faculty directors of core year 3 clerkships (N = 12), and sponsored residency program directors (N = 8). The study had IRB approval.

A questionnaire asked for listings of the most common and important problems encountered with trainee written records. Results were qualitatively analyzed for themes by two independent raters. Ten initial categories were collapsed into four major themes: ‘incomplete,’ ‘unfocused,’ ‘poorly integrated,’ and ‘inappropriate content or format.’

A total of 214 responses were generated by 25 participants. Incomplete written records accounted for approximately one-third of the problems listed by each respondent group. The most frequent themes varied by respondent group: graduate assistants reported inappropriate content and formatting most often (46% of the comments). In comparison, clerkship directors indicated incomplete written records as the most frequent problem (32% of the problems) among clinical students. Residency directors noted poor integration as the most frequent problem (31% of the comments). Our results suggest differing viewpoints from the groups of medical educators we sampled, and likely relate to the acquisition of written record skills as a developmental task.

The next step will be to work toward creating more standardized faculty expectations and a set of tools with explicit grading criteria across our preclinical and clerkship experiences. We are hoping to change the trainee–teacher conversation about written records from ‘That's not how they taught me!!!’ and ‘What are they teaching you?’ to ‘This is what I’ve learned so far’ and ‘Let's take it from there.’

Dianne Wagner

John Radford

Brian Mavis

Michigan State University

College-wide Assessment

East Lansing

Michigan

USA

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First Brazilian experience in web-based course for healthcare professionals

Dear Sir

Antimicrobial resistance (AR) is an important worldwide public healthcare problem. Studies show that healthcare professionals’ (HCPs) education and knowledge are key determinants of adequate antimicrobial use and AR control. Brazil has a large territory – more than eight million square kilometers and limited resources make it difficult for HCPs to leave their work sites for long training courses. The Infectious Diseases Division and the Health Informatics Department of the Federal University of São Paulo have designed a web-based course (WBC) on AR control for physicians and other HCPs from different regions of Brazil. It was supported with funds from a collaborative project involving the Pan American Health Organization (PAHO), the National Health Surveillance Agency (ANVISA) and the Ministry of Health in Brazil and offered at no cost to all selected applicants. All Brazilian hospitals were contacted by e-mail or mail in an attempt to ensure at least one applicant from each site. The program layout included a printed book and a CD-ROM, posted to the participants’ address, and the development of a website using the Modular Object-Oriented Dynamic Learning Environment platform (Moodle). Participants were monitored through their accesses to the website, participation in forums and discussions boards via e-mail with the tutorial team. A 70% average grade was required for approval. Based on pre- and post-training surveys, prior and newly acquired knowledge were assessed. A total of 1172 HCPs were accepted for the WBC and 1027 participants completed the course. The difference between pre- and post-training mean test scores, defined as knowledge gain, was 15.6% ± 6.2% (p < 0.001). Overall, participants were very satisfied with the relevance (68.0%) and up-to-date content (72.1%) and with the opportunity to exchange experiences with other professionals (78.4%). The WBC was shown to be an effective approach, especially in the context of a large, developing country with limited teaching resources. It allowed the exchange of experiences between professionals while keeping them close to their work sites, promoted simultaneous knowledge acquisition by a large number of participants and reached some remote areas. This first course was made available from October 15 to December 14 2007 and now other Brazilian HCPs are currently receiving the same training.

Carla Morales Guerra*, Monica Parente Ramos and Eduardo A. Servolo Medeiros

Federal University of Sao Paulo

Rua Napoleao de Barros,

690 – 2andar

São Paulo 04024-002

Brazil

*Email: [email protected]