Medical education in difficult circumstances
Do longitudinal integrated clerkships promote continuity of care?
How can we use consensus group methods in educational research?
How can a progress test be embedded in an assessment programme?
Medical education in difficult circumstances: A global responsibility to contribute
Michelle McLean, Judy McKimm and Trevor Gibbs
The context in which education and training occurs is far from even. Many educators face challenges in providing health professions’ education, ranging from individual challenges and organisational struggles, through to working in countries experiencing major conflict or environmental disaster. This commentary sets the scene for an international discussion on might constitute ‘difficult circumstances’ and invites educators from around the world to contribute to the discussion.
‘Compared with … major global issues, the ‘difficult circumstances’ in which some educators find themselves may seem mundane, perhaps even trivial. But, the impact of the economic downturn, health service education that functions on goodwill, having to deliver education and training in rural and remote communities, as well as the increased demands and workloads on educators cannot be dismissed. For many educators (and for today’s health professional students who will be tomorrow’s educators), working and leading at the interface of education and health is challenging and stressful.’
Longitudinal integrated clerkships
Judith Nicky Hudson, Ann N. Poncelet, Kath M. Weston, John A. Bushnell and Elizabeth A. Farmer
Emphasising continuity as the organising principle of a longitudinal integrated clerkships (LIC), this article reviews evidence and presents perspectives of LIC participants concerning continuity of care, supervision and curriculum, and continuity with peers and systems of care. It also offers advice on implementing or evaluating existing LIC programs.
‘Continuity, rather than fragmentation, is the organizing principle of a longitudinal integrated clerkship (LIC). Continuity drives the outcomes for LIC participants: students, patients, preceptors, peers, communities, and healthcare systems.’
Using consensus group methods such as Delphi and Nominal Group in medical education research
Susan Humphrey-Murto, Lara Varpio, Carol Gonsalves and Timothy J. Wood
Consensus group methods are widely used in research to identify and measure areas where incomplete evidence exists for decision-making. This paper outlines a series of recommendations to assist researchers using consensus group methods in providing a comprehensive description and justification of the steps taken in their study.
‘Just as clinicians regularly make difficult choices about treatment options, health professional educators must make decisions in the face of uncertainty. In medical education, consensus group methods are used to determine components of a new or revised curriculum, develop items for assessment tools, define competencies, and develop educational resources .’
A framework for negotiating positionality in phenomenological research
Robin M. Hopkins, Glenn Regehr and Daniel D. Pratt
Phenomenology allows us to understand and appreciate educational issues by exploring the unique experiences and perspectives of individuals involved in the process. There are certain core tenets to all phenomenological research, such as a focus on exploring experience and adopting a phenomenological stance. However, because phenomenology has emerged from the work of a number of related but distinct philosophers, phenomenologists do not adhere to a single approach. To help phenomenological researchers position themselves and their work with regard to the various approaches, this article offers the “3 + 1” framework.
‘Often when we want to learn about something, be it a place we are going to travel to or a restaurant we want to visit, we take the initiative to talk to and learn from others who have already experienced those things … Thus, when we want to learn more about a certain thing or place, we often look to the experience of others. Similarly, phenomenology is an approach to research that turns to people’s experiences in order to better understand something.’
Twelve tips for applying the science of learning to health professions education
H. C. Gooding, K. Mann and E. Armstrong
Findings from the science of learning have clear implications for those responsible for teaching and curricular design. However, this data has not been generally explored by educators in practice, including those in health professions education. In this article, the authors aim to bring practical tips from the science of learning to health professions educators.
‘Individuals constantly take in information through their senses and hold this temporarily in working memory. As the capacity of working memory is finite, information must be processed and stored in long-term memory for later use. Information in long-term memory is organized into schemas of increasing complexity, allowing individuals to retrieve a schema for use in?working memory as a single construct. Cognitive load theory CLT divides learning further into the intrinsic load of the information to be learned and the extrinsic load required to process it.’
Twelve tips for assessing surgical performance and use of technical assessment scales
Jeanett Strandbygaard, Fedde Scheele and Jette Led Sørensen
The aim of this twelve tips article is to provide a critical and useful appraisal of some of the common questions and misunderstandings regarding the use of surgical assessment scales, and provide tips to ease and overcome potential pitfalls.
‘It is generally accepted that assessment drives learning and that an objective assessment tool can aid surgical training by helping the process through constructive feed- back on operative performance. Assessment in general plays an integral role in any physician’s professional development and in the identification of his or her own learning needs, and it should ideally provide insight into actual performance.’
Preclinical medical student observations associated with later professionalism concerns
Cynthia A. Burns, M. Ann Lambros, Hal H. Atkinson, Greg Russell and Michael T. Fitch
Professionalism is a core physician competency, and identifying students at risk for poor professional development early in their careers may allow for mentoring. This study identified indicators in the preclinical years associated with later professionalism concerns.
‘The education of physicians requires many elements, from knowledge and skill acquisition, to humanism and personal wellness development, and each element must be multifaceted. Professionalism is one critical facet of physician education, but the search for comprehensive professional development curricula continues.’
Embedding of the progress test in an assessment program designed according to the principles of programmatic assessment
Sylvia Heeneman, Suzanne Schut, Jeroen Donkers, Cees van der Vleuten and Arno Muijtjens
Progress testing is usually one of the assessment methods of the cognitive domain. There is limited knowledge on how positioning of progress tests (PTs) in a program of assessment (PoA) influences students’ PT scores, use of PT feedback and perceived learning value. This study concluded that embedding the PT in an assessment program designed according to the principles of programmatic assessment positively affects scores, feedback and learning value.
‘If the primary purpose of the PT is to drive student learning, feedback on performance is important. Even more important is that the students will look back at and use this feedback information. It is well known that a pass on a summative, consequential test will not encourage students to look back at and learn from the feedback and use it for future learning. A programmatic assessment model has been proposed to optimize the use of assessment information and feedback for self-regulation of learning by students.’
Simulation fails to replicate stress in trainees performing a technical procedure in the clinical environment
B. G. Baker, A. Bhalla, B. Doleman, E. Yarnold, S. Simons, J. N. Lund and J. P. Williams
Simulation based training (SBT) has become an increasingly important method by which doctors learn. Stress has an impact upon learning, performance, technical, and non-technical skills. However, there are currently no studies that compare stress in the clinical and simulated environment. This paper compared objective (heart rate variability, HRV) and subjective (state trait anxiety inventory, STAI) measures of stress theatre with a simulated environment.
‘The master-apprenticeship “see one, do one” approach to medical education has stood for some time. The potential impact of this approach upon patient safety is unacceptable. Trainees must now climb the “learning curve” without exposing patients to preventable errors.’
Managing extremes of assessor judgement within the OSCE
Richard Fuller, Matt Homer, Godfrey Pell and Jennifer Hallam
Post-hoc analysis can be employed to identify some elements of ‘unwanted’ assessor variance. However, the impact of individual, apparently ‘extreme’ assessors on OSCE quality, assessment outcomes and pass/fail decisions has not been previously explored. This paper uses a range of ‘case studies’ to illustrate the impact that ‘extreme’ examiners can have in OSCEs, and gives pragmatic suggestions to successfully alleviating problems.
‘The design of the OSCE has traditionally been viewed as advantageous in nullifying individual behavioral judgment effects seen in other test formats through its use of multiple assessor–candidate interactions across stations. However, OSCEs can be prone to high levels of error variance due to inadequate sampling, poor station design, and individual differences in assessor decision making, often perhaps simplistically characterized as “hawks and doves.”’
The impact of socially-accountable health professional education: A systematic review of the literature
Carole Reeve, Torres Woolley, Simone J. Ross, Leila Mohammadi, Servando Halili Jr, F. Cristobal, Jusie Lydia J. Siega-Sur, and A.-J. Neusy
This literature review describes the impact of health professional schools with a social accountability mandate by identifying characteristics of medical education found to impact positively on medical students, health workforce, and health outcomes of disadvantaged communities.
‘There is often a significant mismatch between health professional education and the needs of the local health system as an inevitable consequence of limited collaboration between the health and education sectors; compounded by weak links between educational institutions and the health system that employs their graduates. The under-representation of certain social and cultural groups in higher education is a worldwide phenomenon and top-down approaches to widening participation have had limited success.’
Use of the pause procedure in continuing medical education: A randomized controlled intervention study
Lukas W. Richards, Amy T. Wang, Saswati Mahapatra, Sarah M. Jenkins, Nerissa M. Collins, Thomas J. Beckman and Christopher M. Wittich
During lectures, a pause procedure can improve educational outcomes. In this randomized controlled intervention study, the authors aimed to determine whether continuing medical education (CME) presentations with a pause procedure were evaluated more favorably and whether a pause procedure improved recall.
‘Principles of adult education provide direction for creating more effective learning in continuing medical education (CME). Traditional lectures are the most common method for delivering CME. Lectures require long attention spans, yet research has shown that concentration and knowledge recall decrease sharply after 10–15min and that learners recall 70% of the material from the first 10 minutes of a lecture, whereas only 20% of the material presented from the last 10 minutes.’
Medical education of attention: A qualitative study of learning to listen to sound
Anna Harris and Eleanor Flynn
Training the senses is a critical aspect of diagnosis that needs to be better addressed in medical education. By incorporating theoretical insights into ‘attentiveness’ from anthropology and science and technology studies, this article suggests that musical education provides medical students with skills in sensory awareness.
‘The teaching and learning of physical examination skills in medicine has become contentious. Some clinicians question the usefulness of subjective, sensory examination techniques in an era of rapid technological advances in diagnosis. Others argue that the performance of examinations remains an important aspect of medical care and requires training even though other modalities can provide the same diagnoses. Despite the controversy, little is known about how physical examination skills are, and have been, learned, particularly the sensory and subjective aspects of learning such skills.’
Not all unprofessional behaviors are equal: The creation of a checklist of bad behaviors
Michael J. Cullen, Mojca Konia, Emily Borman-Shoap, Jonathan Braman, Ezgi Tiryaki, Brittany Marcus-Blank and John S. Andrews
Professionalism is a key component of medical education and training. However, there are few tools to aid educators in diagnosing unprofessional behaviour at an early stage. The purpose of this study was to employ policy capturing methodology to develop two empirically validated checklists for identifying professionalism issues in early-career physicians.
‘Studies have shown that professional behaviors such as teamwork and respect are correlated with improved patient outcomes, higher patient satisfaction and greater adherence to treatment plans. Conversely, unprofessional behaviors are associated with negative faculty assessments of professionalism and later disciplinary action by state medical boards. In addition to their effects on individuals, breaches of professionalism can have significant group-level costs by negatively affecting the reputation of the medical profession itself.’
Understanding the influence of different cycles of an OSCE exam on students’ scores using Many Facet Rasch Modelling
Peter Yeates, and Stefanie S. Sebok-Syer
OSCEs are commonly conducted in multiple cycles, yet the potential for students’ allocation to different OSCE cycles is rarely considered as a source of variance - perhaps in part because conventional psychometrics provide limited insight. In this study, Many Facet Rasch Modelling (MFRM) was used to estimate the influence of ‘examiner cohorts’ on students’ scores within a fully nested multi-cycle OSCE.
‘Objective structured clinical exams (OSCEs) were developed in the 1970s in response to overt problems with examiner subjectivity and variable case mix in exams. Whilst OSCEs arguably comprise one of the more important innovations in medical education during the twentieth century, it is clear that they only partly overcome the problem of examiner subjectivity.’
Attending rounds: What do the all-star teachers do?
Frank W. Merritt, Melissa N. Noble, Allan V. Prochazka, Eva M. Aagaard and Chad R. Stickrath
Daily attending rounds, when done correctly, provide numerous opportunities for high-impact teaching in a setting where learners are likely to be motivated, engaged, and able to make immediate use of the new skills or knowledge they acquire. This article examines differences in the types of teaching activities performed during rounds between the most effective and least effective inpatient teaching attendings.
‘When conducted ineffectively, rounds can be lengthy, redundant, and provide little educational content for learners. Moreover, most clinical teachers report not having enough time to teach their teams while attending. The implementation of resident work hour limitations has led to even greater time constraints and perhaps had unintended effects on education.’
Becoming a member of the team
Christopher E. Gaw
Changes in modern medicine, ranging from duty hour limitations to compression of on-service time, have transformed the dynamics of medical teams. In this piece, the author explores the impact that these changes have had on both medical education and physician and trainee well-being.
‘By the end of my month-long rotation, I felt isolated. Rather than working together to advance patient care, team members were completing tasks in parallel, interacting in person only when necessary. Everyone seemed to be minimally invested in each other, both personally and professionally. I could not help but wonder – has the clinical team always operated this way?’
The art of presenting – Failures, fonts and the future
Peter Keogh
Who are ‘expert presenter’ teachers? Some people have it and some people don’t – right? This short piece explores what it is to present, how this evolves and attempts to pin down the why rather than the how.
‘My first real and proper exposure to what I have always thought of as lectures are from medical school. Apart from taking place in an eponymously named room with a brass plaque above the door, it was where people presented to you. Usually, hours worth of mind-numbing facts via an over-head projector, the contents of which would form the basis for some kind of examination, and so had to be copied down in its entirety usually without thought.’
AND IN THE LETTERS …
Responses to Medical Teacher articles
Empathy and self-preservation amongst medical students
Discourse analysis in interprofessional education