Letters to the Editor

The use of (silent) mannequins to teach communication skills to medical students: An experimental approach in Italy

Dear Sir

Usually, students involved in communication classes in medicine interpret communication as the acquisition and use of only verbal and non-verbal skills. However, students report some anxiety in communicating with silent and distressed patients. In fact, they believe that communication implies a minimal verbal interaction between doctor and patient. Nevertheless, there may be many reasons why patients refuse to talk, are unable to talk, or even are incapable to understand what is communicated. For example, severe stress, depression, anxiety, confusion, and organic states may impede a clear speech and create some difficult comprehension of doctor's intentions. Hence, medical students shall learn to use a supportive and empathic communication to alleviate discomfort in silent patients. Communication with Silent Mannequins (CSM) implies three stages: (i) doctor verbalising client's hypothetical feelings at the moment, e.g., “It's not easy to accept the death of a close friend”; (ii) offering non-verbal support, e.g., a glass of water, a handkerchief, etc.; (iii) learning to disclose positive feelings towards patient and to act as advocate, e.g., “I’m available to talk to you anytime you need me”. During the course in CSM, medical students learn to maintain an empathic and supportive conversation with a (silent) mannequin for not less than 20 minutes. They also learn not to interpret silence as a barrier between them and their patients. Instead, students use this moment as an opportunity to help distressed patients to a more bilateral exchange. Finally, this course attracts students with different learning styles (Honey & Mumford 2009). The “theorist” feels challenged by this creative opportunity and would make personal speculations on the best words to approach silent clients. The “pragmatist” feels that interaction with silent mannequins is stimulating as it creates opportunities for direct application into practice. The “activist” feels enthusiastic because during the interaction with “silent clients” s/he puts in all personal efforts in the full support of potential clients. Finally, the “reflectors” are good at managing long-time silence and use these moments for reflection on the course of actions and best words to support silent patients.

Carlo Lazzari, Centre for Health Education, Via Raiale 112, 65128 Pescara, Italy. E-mail: [email protected]

Boundaries around the drug industry: A prescription

Dear Sir

Scrutiny of the relationship between the pharmaceutical industry and doctors raises concerns about appropriate contact between learners and “drug reps.”

First year students at our institution participate in a course entitled “The Patient-Physician Relationship” (IPPR). One of the units discusses “Boundary Issues in Medicine (BIM),” and a unique student experience is employed to trigger reflection about students and the pharmaceutical enterprise.

Large lecture formats present impediments to teaching material with an affective component. Novice students are challenged to identify a situation where a fiduciary responsibility is being tested. Paper cases try to recreate the necessary tension, but do not always feel authentic to students with little relevant experience. Course faculty wanted a more effective representation of a boundary violation related to the pharmaceutical industry.

The “BIM” presentation centers on a faculty panel discussing boundary issues faced during their training and practice. It starts with a fake “drug rep” addressing the students about a fictitious nutritional product and company, and informing them that the meal outside the lecture hall is courtesy of “Oncocorp.” The meal is arranged so that students view it as they enter lecture. The panel is introduced and discusses their experiences. Student questions are encouraged and responded to. This food has, in reality, been purchased by the College. A student usually comments upon the possible inappropriateness of having a “drug rep” address students and bring food for them. Once this question is raised, multiple students in the audience echo the concern. Students are then informed of the true nature of the “rep” and of the reason for the “set-up.” If no student asks the question, they are informed and an explanation is offered before the end of the session.

Students often state: “something didn’t feel right about having the drug rep.” Students rate this course experience as 4.0 out of 5 on a Likert scale with 5 being “highly effective.” On that scale, student responses to specific questions were: “When I thought that the “rep” was real, I felt uncomfortable” (3.7/5), “The presentation provided a venue for thoughtful reflection on the role of the … industry” (3.7/5), and “The temporary deception … to underscore the “drug rep” issue was acceptable to me” (3.8/5). Faculty answered the question “The Fake Drug Rep portion was an effective way to help students understand (this) issue” with 4.4/5 indicating strong support for the curricular innovation.

Dianne P. Wagner & Janet R. Osuch, Michigan State University College of Human Medicine, A102 East Fee Hall, East Lansing, MI 48824, USA. E-mail: [email protected]

Research as a syllabus in medical undergraduate curriculum: Is this important in nurturing future researchers?

Dear Sir

Research in undergraduate medical curriculum has been a topic of debate. We believe that exposing undergraduate medical students to active research not only makes them efficient researchers but also familiarizes them with various research ethics and protocols. The research exposure enriches the young individual with proper knowledge which may be lacking in standard textbooks. This exposure to research helps undergraduate medical students realize the importance of research at an early stage. Unfortunately, all over the world, both undergraduate and postgraduate medical students seem to be less interested in pursuing active research. They prefer to opt for professional and financial benefits.

Due to the recent economic recession, many developing countries are handicapped by paucity of research funds. This often compels researchers in these countries to seek better pastures overseas. Even in the advanced countries, there is severe competition amongst researchers. There is an urgent need to keep medical research alive in the developing and developed countries. At Universiti Kebangsaan Malaysia, medical students have a compulsory Special Study Module (SSM) which exposes them to active research in their fourth year. These efforts have borne fruit. The students learned to conduct proper research, exhibited good team work skills and even published papers and perfected the technique of presenting papers at international conferences. Some of the medical conferences even encouraged young researchers to present their papers. These were Malaysia Indonesia Brunei conference (held annually on rotation basis in south-east Asia), Leiden International Medical Student Conference (Amsterdam 2011) and the International Anatomical Science and Cell Biological Sciences Conference (Singapore 2010). Some international publications in Medline-indexed international journals also boosted the morale of the young researchers from South-east Asia (Azlin et al. 2010; Keat et al. 2010). Many international journals like Student British Medical Journal, Australian Medical Student Journal, Journal of American Medical Association and Trinity Student Medical Journal (Dublin) have published student-related research articles.

An earlier author reported that research is mandatory in Germany and it could significantly influence the publication output of the entire medical faculty (Cursiefen & Altunbas 1995). Student-conducted research may contribute a lot to the medical faculty's progress. Thus, it is necessary that many international organizations and funding bodies should voluntarily develop effective research programmes and financial support to encourage the budding medical doctors. If we nurture the plant before the flower blossoms, we are sure that the entire society will reap the benefit at a later stage.

Srijit Das, Department of Anatomy, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abd Aziz, 53000 Kuala Lumpur, Malaysia. E-mail: [email protected]

Nor Azlin Mohamed Ismail, Universiti Kebangsaan Malaysia Medical Center, Malaysia

Examiners’ perception of Objective Structured Examination in colposcopy

Dear Sir

Certification in colposcopy by the British Society for Colposcopy and Cervical Pathology (BSCCP) and the Royal College of Obstetricians and Gynaecologists is a formal pre-requisite to the practice of colposcopy within the UK. This certification is awarded after passing an Objective Structured Clinical Examination (OSCE). The aim of this project was to explore examiners’ perceptions of the OSCE examination in colposcopy. A case study research methodology was employed for the project and questionnaires were sent to 30 examiners for OSCE in Colposcopy. This project also included conducting semi-structured interviews (SSI) with two examiners, two trainees and a senior manager of the BSCCP. The questionnaire had a response rate of 28 (94%).

Do the examiners regard the OSCEs as boring? The question was posed to the examiners in questionnaire and also in SSI. The examiners did not regard OSCE as boring. The OSCEs are different from the traditional examinations. In OSCEs, examiners are given specific questions and scoring sheets to mark each candidate's response. Examiners are not allowed to ask questions outside given sheets or to use the examination as a tutorial opportunity. However, some of the examiners, especially those who had examined in the traditional system, may find these restrictions to be limiting. Going through 24 candidates (the usual number of candidates in an OSCE in Colposcopy examination) with a similar set of questions could be monotonous. However, OSCE in Colposcopy is run in such a way that examiners do get a break of 10 minutes midway through the examination. A free text comment by a questionnaire respondent could be worthy of BSCCP's attention: to change the examiners station after 12 candidates in order to avoid repetition. However, timing in OSCEs is extremely important and switching and swapping examiners on 10 OSCE stations could be time consuming and may prolong the examination, which may not be liked by the candidates. In a study by Humphris & Kansay (2001), it is acknowledged that OSCEs are time-consuming and could be tedious for the examiners. However, they did not find ‘examiner fatigue’ during the OSCEs associated with any marking errors.

The author is an OSCE examiner for colposcopy.

N. S. Qureshi, Consultant Gynaecologist and Postgraduate Clinical Tutor, Birmingham Women's Hospital, Edgbaston, Birmingham B15 2TG, UK. E-mail: [email protected].

Perceptions of educational climate in a Canadian medical radiation science programme

Dear Sir

The medical radiation science (MEDRADSC) collaborative program at Mohawk-McMaster has undergone curricular reform since its inception in 2004, which is still ongoing. Students’ perception of their educational environment, especially in accredited programs concerned with pressured professional training/education, has been studied at all levels of the education system using psychometric questionnaires. The Dundee Ready Education Environment Measure (DREEM) questionnaire, originally developed by Roff et al. (1997), was used to measure students’ perception of the education environment in medical radiation science overall, by specialization and by gender.

The MoMac Institute for Applied Health Science, located on campus at McMaster University, accepted its first cohort of students in the MEDRADSC collaborative four-year degree/diploma program in 2004. Intake per annum is approximately 150 students with a 1:4 ratio of males to females. The first year of study is common amongst all MEDRADSC students and covers the basic sciences, taught by the McMaster group, as well as introductory courses in MEDRADSC taught by the Mohawk group. Year two and three courses are conducted by the Mohawk group and include courses specific to each specialization. The MEDRADSC program is split over 10 terms with one summer off between year 1 and 2. There are three, 13–15 week clinical phases and they occur between first and second year (phase 1) and in year 4 (phases 2 and 3).

The DREEM instrument was distributed electronically in June 2009, to a total of 105 third year students from three medical radiation specializations: ultrasound, radiation therapy and radiography. The overall response rate was 83% (88/105). Response rate by specialization was largest from radiography with 43/88 = 49%, followed by ultrasound with 26/88 = 29% and finally therapy with 19/88 = 22%. Chi-square test results compared each specialization versus those that did and did not respond and showed no significant statistical difference (χ²= p > 0.05). The demographic profile of respondents by gender mimicked the student population with 21 male (20%) and 84 female (80%). Chi-square test results compared male and female versus those that did and did not respond and showed no significant difference (χ²= p > 0.05).

The mean total DREEM score was 139/200 (70%), indicating relative satisfaction with the environment but with room for improvement (Roff 2005). Use of DREEM as a monitoring tool permits timely interventions by the curriculum development group in MEDRADSC to remediate problematic educational environments. Further studies are needed to analyse all years and also to compare perception of educational environment in collaborative programs versus accredited college diploma programs in Ontario.

Renata Lumsden, Department of Medical Radiation Sciences, Mohawk–McMaster Institute for Applied Health Sciences, 1400 Main Street West, Hamilton, ON, Canada. E-mail: [email protected]

Susie Schofield, Department of Medical Education, University of Dundee, Dundee, Scotland.

An evaluation of a final year work-shadowing attachment

Dear Sir

One of the major aims of medical school is to prepare junior doctors for the first stage of their careers. However, several authors have expressed concern that the transition from student to doctor is a stressful event (Wall et al. 2006; Berridge & Freeth 2007). To help bridge this gap most, medical schools in the United Kingdom incorporate a work-shadowing period (WSP), when final year students spend time with the existing junior doctors, aiming to gain the skills necessary for their working life. At Queen's University Belfast the WSP takes place in May, after the final clinical examinations.

We undertook a study to gain the views of the students undertaking the WSP, as well as Foundation Programme Educational Supervisors and Directors (FPESDs) involved in their supervision. This study utilised both qualitative (focus groups) and quantitative (questionnaire) approaches. The FPESDs completed a questionnaire designed for this study, while the students completed the university's internal quality assurance questionnaire. The focus groups involved up to 20 students in two separate groups (one based in a regional centre and the other in a district general hospital) and occurred at the start and the end of the WSP, as well as 8 weeks into the FY1 year. Twenty-eight of the 37 (76%) FPSDs and 106/196 (54%) students completed the questionnaires. The transcripts of the focus groups were analysed and themes were identified.

We identified several positive aspects of the WSP, in particular, as it exposes students to their future working environment and allows them to learn from those already in post. However, the students felt that more senior input is needed in order to maximise student participation and clinical interaction. Whilst ensuring that patient safety is paramount, students felt the need for more direct responsibility in order to make them feel part of the medical team. Specific scenarios where students do not feel comfortable include drug prescribing and management of medical emergencies, and these areas should be addressed more comprehensively in the undergraduate curriculum. In our study, students were also concerned about the timing of attachment, citing too great a duration between the WSP and working life. They suggested that more emphasis be placed on the revision of clinical and procedural skills during induction, and that the WSP period should be moved closer to the date of working life. Further study is needed to assess the emotional and psychological impacts of the early working period on junior doctors, as well as mechanisms to ease these.

Peter McKavanagh & Pascal McKeown, Department of Cardiology, Royal Victoria Hospital, Institute of Clinical Science, Grosvenor Road, Belfast BT12 6BJ, Ireland. E-mail: [email protected]

David McCluskey & Mauraice Savage, Department of Medicine, Royal Victoria Hospital, Belfast, Ireland

Mairead Boohan, School of Medicine, Queen's University Belfast, Belfast, Ireland

Statistics: A learning needs assessment

Dear Sir

There are few opportunities for statistical training for doctors in postgraduate medical education and training in the UK, despite the need to be able to understand published articles, which contain increasingly more complicated statistical methods. As medicine has become ever-increasingly evidence-based, “medical statistics” has moved up the educational agenda and now commands a heightened place within UK undergraduate medical schools’ curricula. After graduation, however, doctors have little continued training in statistics (Altman & Bland 1991) and much of that is “poor” (Campbell 2002).

Historically, statistical training courses have been developed by statistical experts, without assessing the actual learning requirements of the target audience. Short courses designed by experts alone, with no input from potential learners, may be of little interest or relevance to the target audience. Lack of relevance and/or interest may lead to poor engagement and feedback, and in turn the number of participants falls quickly – an unfortunate finding for many continuing professional development courses.

We undertook a learning needs assessment to identify the current statistical training needs of SpRs within the South West Peninsula of England. This was a descriptive, cross-sectional, online survey, based around 14 statistical topics.

Forty-five SpRs completed the questionnaire, from all years of training. The median number of years since graduation was 9 (range 5–21); 62% of respondents were male. Just under half categorised their speciality as medical or surgical.

78% of respondents considered themselves to be both a “consumer of research” (reading literature, etc) and a “doer of research” (involved in own research or audit); 18% claimed to be solely a “consumer” and 4% indicated that they were solely “doers”.

59% of respondents ranked both “critical appraisal of quantitative research” and “interpreting p-values and confidence intervals when reading papers” as training priorities. Other topics that were ranked highly included “study designs”, “sample size calculations” and “introduction to clinical trials”. Topics that ranked lowest were “multiple linear regression” and “logistic regression”, each a priority for 21%.

This study suggests a clear need for local statistical training within a postgraduate medical training environment and has identified priority topics. The results will aid in the development of tailored and relevant statistical training courses. Whilst the study was undertaken in only one NHS Deanery, it is likely that the results would apply to other areas currently lacking statistical training opportunities. Organisers of statistical training should find the conclusions of this study of interest.

Siobhan Creanor, Centre for Health & Environmental Statistics, University of Plymouth, Room 301, Tamar Science Par, Plymouth PL6 8BX, UK. E-mail: [email protected]

Nick Cooper & Stephen L. Creanor, Peninsula College of Medicine and Dentistry, University of Plymouth, John Bull Building, Tamar Science Park, Plymouth PL6 8BU, UK