Letters to the Editor

Research outputs by medical students from routine public health training projects

Dear Sir

Previous work in the United Kingdom (Edwards et al. 2001) and the United States (Ahlers-Schmidt et al. 2009a, 2009b) indicates that medical student training activities can result in publications in the scientific literature. This prompted us to consider the situation for such outputs arising from public health projects which are part of the curriculum for medical students at our university.

We identified the final reports arising from public health training projects performed by undergraduate medical students over five-week periods (full list available on request). This was for six runs per year over the last five-year period available (up to 2009). We then performed Google searches and Medline searches to determine if the project reports were published in the Medline-indexed literature or on websites. Individual staff supervisors in our Department were also questioned on project outcomes.

Of the 30 project reports identified, eight (27%) resulted in Medline-indexed journal publications (n = 7 articles and one letter; n = 6 in international journals). In six of these publications, the student authors were the lead authors, and there were a total of 81 student authors listed. In addition, these “published” projects also resulted in conference posters (n = 2), a conference oral presentation (presented by the students), reports published on websites (n = 2), follow-on Medline-indexed publications that built on the original work (n = 2; both with at least one student author), and a subsequent research contract on the topic from the Ministry of Health (which involved the staff supervisors). Of the remaining projects (n = 22), two had the final report published on a website. This gave a final total of 30% (10/30) of projects resulting in some form of publication, with an average of 4.7 published or conference-presented outputs per 10 projects.

These results are encouraging but still may under-estimate the resulting outputs as others may still be in progress from projects in 2009 (e.g., one submitted article and two others still being planned according to supervisors). Our impression from end-of-the-run student feedback is that these public health projects are generally valued by them and that the publication outputs are appreciated. However, a barrier to achieve such outputs is that it usually involves additional after-hours student and staff time after the formal run in public health is completed. This could be partly addressed, along with increasing the level of such outputs, by making more of the formal course time available for the “write-up” stage of the project work.

Nick Wilson, Jo Peace & Richard Edwards, Department of Public Health, University of Otago, Wellington, New Zealand. E-mail: [email protected]

State of play: Supporting students with specific learning difficulties

Dear Sir

Recent analysis of a study conducted across all UK-based medical schools reveals interesting information about the current ‘state of play’ regarding support for medical students with Specific Learning Difficulties (SpLD). The investigations were based on structured telephone interviews to gather data from two representatives from each UK medical school (n = 32) and were complemented by data acquired through the UCAS Statistical Service.

Results suggest that there has been a dramatic increase in the number of students, who declare a diagnosis of an SpLD at application, both applying for and being offered places to study medicine between 2004 and 2008. When comparing the number of applications, the proportion of students with a declared SpLD increased by 44%, and those who were offered places increased proportionally by 53%. Over half of the medical schools (56%) actively encouraged disclosure of a learning difficulty during the applications process.

Support provided by academic and administrative staff was, understandably, varied. Many schools had a designated Disability Champion (75%) or provided specifically tailored student support dedicated to medical students (66%). However, only 6% provided both. Encouragingly, 87% of schools provided a dedicated welfare service, with a mean number of 16 students per ‘tutor group’.

Reasonable adjustments were implemented in all institutions, in concordance with UK law (DDA 1995). There was, however, significant variability in the extent to which, and under what circumstances, certain adjustments were provided. Proof reading and the provision of an amanuensis were the least implemented of the nationally recommended adjustments (JCQ 2007). Five medical schools, at the time of the investigations, were experimenting with the implementation of reasonable adjustments during clinical placements and assessments, such as providing extra time between OSCE stations.

The significance of the individual findings is explored in more depth in the full report, which is accessible through the HEA Subject Centre website (www.medev.ac.uk). More work is clearly needed in this area. Little evidence exists to support arguments either for or against the use of reasonable adjustments in medical education. Moreover, unfounded speculation exists as to the extent to which such educational adjustments will impact the practice of medicine as a professional.

Duncan Shrewsbury, Medical School, University of Birmingham, Edgbaston, Birmingham B15 2TT. E-mail: [email protected]

Why formal practice management education is required in the postgraduate medical curriculum

Dear Sir

As increasing demands on health care services are posing new challenges to practicing physicians worldwide, physicians have to extend existing and develop new competencies in various domains of their profession. Management and leadership is one of these domains, and relevant competencies have been incorporated in many new competency-based (postgraduate) training programs. Among trainee physicians and clinical educators, however, there is still a poor understanding of the definition and content of the physician's competency as manager. For this reason, a review of the literature was conducted to identify any specific knowledge, skills and attitudes required for the development of managerial competencies in physicians. We were interested in establishing the extent to which competency-based curricula equipped medical trainees in their managerial competencies and if there were programs specifically designed to develop these competencies (Busari et al., in press).

Forty relevant articles were retrieved from our PubMed search that addressed residents’ needs for management education and also described the design, implementation and evaluation of management education curricula. Most of the studies were conducted in North America and within the family medicine specialty. The most commonly taught topics were: finance, management and quality assurance. In all these studies, the training resulted in improved knowledge and skills in management issues. Furthermore, these programs were evaluated positively despite the use of different educational methods (Busari et al., in press).

Presently, education in health care management has become an essential requirement for many practicing physicians. Unfortunately, there is still no consensus as to when, in what form and for how long such a program should be introduced into the postgraduate medical curriculum (Bohmer 2010). In an attempt to obtain an understanding of this situation, we decided to investigate medical residents’ needs for management training and identify the preferred method of intervention to develop their management competencies. 506 Dutch medical residents were invited to participate in the web-based survey of which 177 (35%) responded. In this study, majority of the respondents 85% (n = 146) reported a need for management training with more than half of them (60%) feeling confident in their negotiating skills. 56% of the respondents stated that they lacked sufficient knowledge of how the Dutch healthcare system was financed and organised. 85% felt confident in their ability to handle feedback, 95% could manage medical information data confidently while 81% felt they could allocate healthcare resources effectively based on evidence-based principles. About one-third gave neutral ratings in negotiating career prospects, possessing adequate leadership skills and knowing how to deal with medical errors. The management topics of interest included negotiation skills, practice partnerships, knowledge of the health care system and career planning. The preferred method of instruction was the workshop given by a medical specialist or an external content expert and the preferred moment for the training was during the residency.

In conclusion, the current information on practice management education shows that a lot still needs to be done to prepare physicians for the emerging challenges of managing health care practices. Although the evidence in the literature is insufficient to demonstrate the impact of specific management training modalities on the outcome of care at the end point of service, there is a clear signal that attention should be given to the preparation of residents for practice/care management responsibilities during their training (Bohmer 2010). Finally, while the findings in our review failed to offer evidence to support any specific recommendations for an ideal training program, we strongly believe that management-training programs should be formally incorporated into the curricula of all medical programs and preferably during the residency period.

Judith W.M. Brouns & Jamiu O. Busari, Faculty of Health, Medicine and Life Sciences, University of Maastricht, Universiteitsingel 50, 6200MD Maastricht, The Netherlands. E-mail: [email protected]

How representative are the representatives?

Dear Sir

Student evaluation can be an important tool in course evaluation (Wahlqvist et al. 2006). Using feedback from representatives could potentially reduce the resources required to gather feedback from the students. Very little has been published regarding the reliability of feedback from student representatives. We investigated to see if the feedback from student representatives reflects the opinion of the student body.

Feedback questionnaires were distributed to:

• Thirty-two student representatives

• All first and second year medical (332) students.

Responses were received from:

• 85% of the medical students

• 91% of the representatives.

The data was classified into themes and a code was assigned to each one. The number of students and representatives whose feedback matched the codes was compared. There were significant discrepancies between the themes commented on by the two groups.

• Twenty-four themes appeared in the representatives’ feedback which were only commented on by four or less students in the whole year.

• Four themes were commented on by ten or more students but were not mentioned by the representatives.

• Ten comments made by the representatives did not appear in the feedback from the whole year.

These results highlight the risk of making unnecessary changes to a curriculum in response to group representatives’ feedback, when the issues raised are not of importance to the students as a whole.

Issues of importance to the student body may be missed, as they may not feature in the representatives’ feedback. For example, one of the themes raised by the student body but not the representatives was that some of the course materials were irrelevant. This brought about a course review which led to some of the content being removed; this would not have happened had we relied solely on the representatives’ feedback.

These findings highlight an area which needs further research, as they raise the possibility that group representatives’ feedback does not represent the opinion of the student body. It also raises doubts as to the reliability of such data as a quality indicator, or as the source of pressure to change course content.

Penny Lockwood & Julian Davis, Undergraduate Community Medical Education, Division of Clinical & Population Sciences & Education, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK. E-mail [email protected]

Factors associated with suicidal ideation in Taiwanese medical students

Dear Sir

Suicide rates continue to rise all over the world but particularly in adolescents. One group at high risk for suicide is medical students (Dyrbye et al. 2008). Identification of risk factors associated with suicidal behavior can allow medical school administrators to target specific hig-risk students for intervention (Goebert et al. 2009). The purpose of this study is to determine the rate of suicidal ideation among students at a Taiwanese medical school and to identify specific associated factors.

Students admitted to National Yang Ming University from 2003 to 2007 were assessed by questionnaire on a number of topics. Of the 435 students included in the analysis, fifty (11.5%) presented with suicidal ideation. Students with non-inflammatory joint pain (p = 0.02), headache (p = 0.047), and sleep disorders (p = 0.04) were all significantly more likely to have experienced suicidal ideation. Students with mental stress (p = 0.04), living stress (p = 0.03), who scored as depressed on the Taiwanese Depression Questionnaire (TDQ) (p < 0.01) and/or abnormally on the Chinese version of the General Health Questionnaire (CHQ) (p < 0.01), or who had parents with no college degree (p = 0.04), were significantly more likely to have experienced suicidal ideation.

The high rate of suicidal ideation in such a distinguished population is worrisome and is certainly worthy of study and reflection. Previous studies addressing suicide risk in young men and women focused on psychological factors and emotional stress. Our results indicate that a number of factors including physical health and parents' education may also be associated with suicidal ideation. Students with non-inflammatory joint pain, headache, and/or sleep disorders should be assessed for depression and suicide risk. Medical schools may also wish to administer mental health screening tools to identify and refer high-risk students for appropriate counseling and assessment.

A.P. Fan, R.O. Kosik, T.P. Su, F.Y. Lee, M.C. Hou, Y.A. Chen, C.H. Chen & C.H. Lee, National Yang-Ming University, Faculty of Medicine, P.O. Box 22072, Taipei 100, Taiwan. E-mail: [email protected]