Letters to the Editor

Where are all the sick patients? The need for increasing use of simulation training

Dear Sir

With the introduction of the European working time directive and shift-based work patterns, doctors are suffering from a reduced exposure to medical emergencies. This requires alternative training to make up for a lack of ‘training on the job’. Simulation training is one of these methods. This field was originally dominated by training anaesthetists but is increasingly used in emergency medicine and surgical training.

There are many advantages to this form of training, these include:

1. Trainees can take lead roles in situations beyond their clinical experience.

2. Scenarios are easily repeated and standardised for use in examinations.

3. Simulations are easily recorded, for playback and further assessment

4. Uncommon but serious scenarios can be reproduced readily.

5. The training does not expose the student or any patients to risk or danger.

As with any training tool there are of course disadvantages, these can be:

1. The set-up and running of these simulators can be extremely expensive, although the introduction of portable “set-ups” should reduce costs (Kneebone et al. 2010).

2. There can be no substitute for real patients, simulators are currently not complex enough to truly replicate a genuine sick patient.

3. Due to the simulated nature of the environment, it requires great skill on the part of the trainer to simulate or confer accurately the stress and anxiety caused by treating a real patient

We have had contact with this form of training at two separate centres but due to a lack of funding we were only able to take part in simulation training once during each “Foundation” year even though evidence shows the beneficial effects of repeating simulation training (Holcomb et al. 2002).

Our positive personal experiences, together with a growing evidence base can only mean that this will continue to grow as an essential part of medical education. One of the main reasons for the current situation is lack of resources but this is sure to change as the importance of new forms of training, in the face of reduced patient contact hours, is realised.

C. Macdonald, A. Self, M. Memtsa

Lister Hospital

SG1 4AB Stevenage

Hertfordshire

E-mail: [email protected]

Evaluation of residents’ competency in professionalism and communication skills in northern China: A 360-degree assessment

Dear Sir

Compared to the “basic requirements and standard” given by Accreditation Council for Graduate Medical Education, medical education plan in China is still lacking in a specific evaluation standard for professionalism, interpersona and communication skills which effectively demonstrate physician's acquisition and appropriate use of the other competencies, such as patient care, medical knowledge and systems-based practice (Lyss-Lerman et al. 2009). The aims of this survey were to assess Chinese residents’ professionalism, interpersonal and communication skills in China.

In October 2007, a total of 354 resident doctors of 11 hospitals from seven provinces in northern China were evaluated by attending physicians, residents, nurses, patients, office staffs and resident peers using a 360-degree questionnaire (Education Outcomes Service Group (EOS Group) 1992; http://azmec.med.arizona.edu/eos.htm. pp).

All 354 questionnaires were returned. Cronbach's alpha for the attending-, resident self-, nurse-, patient-, office staff- and resident peer-rated questionnaires were 0.93, 0.94, 0.95, 0.94, 0.91 and 0.94, respectively. The evaluation results of residents’ competency in professionalism show the difference in the scores of attending physicians (74.6–79.25), resident self (73.39–79.70), nurses (86.65–93.67), patients (31.09–34.55), office staff (48.58–54.83) and resident peers (73.66–79.30). The score of resident self was higher than those of other evaluators. The evaluation results of a resident's competency in interpersonal and communication skills also vary in the scores of attending physicians (22.78–24.6), resident self (23.19–24.81), nurses (32.49–34.69), patients (30.78–34.19), office staff (18.22–19.85) and resident peers (22.88–24.55).

Our survey demonstrates that the 360-degree evaluation is a significant and effective method to assess the professionalism, interpersonal and communication skills. Formative feedback will be provided to each resident and suggestions for improvements will be made. In this way, a progressive improvement in professionalism, interpersonal and communication skills could be encouraged and measured.

Bo Qu

School of Public Health

China Medical University

Shenyang, China

Yun-Hong Zhao

School of Continuing Education

China Medical University

Shenyang, China

Bao-Zhi Sun

Research Center for Medical Education

China Medical University

Shenyang, China

E-mail: [email protected]

Evaluating effectiveness and usability of an e-learning portal: The e-MedEdu site

Dear Sir

The Korean Consortium for Medical Education in e-Learning, which comprises of 31 Korean medical schools, launched an e-learning portal (www.mededu.or.kr) to provide medical students with quality online learning resources. In this e-learning portal (henceforth, e-MedEdu), students have access to various online learning resources, including virtual patient cases, video clips for clinical skills education, clinical images, and quizzes (Kim et al. 2009). To make this website more effective, efficient, and satisfying for the users, we have conducted formative and summative evaluation on it.

Usability and accessibility are key to creating successful e-learning systems (Masters & Ellaway 2008; Sandars 2010). A formative evaluation of the usability of e-MedEdu was performed using a usability testing method. Usability testing is an approach to ensure the usability of a product, such as a computer program or a Web site, from a user-centered design principle by observing real users perform authentic tasks with the product (Rubin 1994). Additionally, a questionnaire was administered for students registered in e-MedEdu to investigate their perceived value of and satisfaction with e-learning.

Thirteen students from two medical schools participated in two rounds of usability testing. Five students participated in one-on-one usability test sessions, and eight students were tested by a remote usability testing method (Rubin 1994). Some recommendations were made to improve the usability from the results of the usability tests and the website was revised based on that feedback. 153 students from 29 medical schools completed the survey for summative evaluation. 40% were female and 60% were male. 42.5% of the participants were fourth-year students, 25.5% were third-year students, 22.2% were second-year students, and 3.3% were first-year students. The questionnaire asked about the type of content in e-MedEdu the participants used most often and was most useful for them. 44% of those surveyed accessed clinical skills videos most often, followed by virtual patient cases (41%) and quizzes (25%). Similarly, the participants answered that clinical skills videos were most useful (35%), followed by virtual patient cases (29%) and quizzes (8%). Rated on a four-point Likert scale, with 1 being “strongly disagree” and 4 being “strongly agree,” the survey participants agreed with the statements that the online learning resources were useful for their learning (M = 3.04 SD = 0.325), in particular, for acquiring clinical skills (M = 3.14 SD = 0.505). The participants also agreed with the statement that they would keep using the e-MedEdu site (M = 3.09, SD = 0.560). The participants’ overall satisfaction with e-MedEdu was significantly correlated with their perceptions of comprehensiveness of the content in the repository (r = 0.400, p < 0.01), quality of the content (r = 0.517, p < 0.01), and usability of the website (r = 0.444, p < 0.01).

The present study evaluates preliminary impacts of the unprecedented collaborative efforts by Korean medical schools to offer e-learning for medical students. The results show that students perceive it valuable to have access to online learning resources and are satisfied with the quality of the content. Overall, students benefit from using this e-learning portal and it can have greater impacts by building up the content repository, making it a more comprehensive one.

Kyong-Jee Kim

Office of Medical Education

Sungkyunkwan University School of Medicine

Seoul, Korea

E-mail: [email protected]

Joungho Han

Department of Pathology, Samsung Medical Center

Sungkyunkwan University School of Medicine

Seoul, Korea

Ie Byung Park

Division of Endocrinology and Metabolism

Gil Medical Center

Gachon University of Medicine and Science

Icheon, Korea

Changwon Kee

Department of Ophthalmology

Samsung Medical Center

Sungkyunkwan University School of Medicine

Seoul, Korea

Research using SSCs

Dear Sir

The student selected component (SSC) of medical undergraduate curricula should drive “the intellectual development of students through exploring in depth a subject of their choice” (GMC 2009). When an SSC involves any form of research, the problems encountered include failure of students to complete research within institutional deadlines, increasing administrative workload, and discouraging creativity in student led research (Robinson et al. 2007). We offer an example of how our medical school responded to this problem.

A panel of 10 clinicians/ethics panel members were involved in a two-part decision Delphi technique to collate and present views of the panel on whether or not standardised SSCs required ethics review or approval. Each member of the panel voted online, and were blinded to the identities of other panel members’ opinions. Of the 10 scenarios, three were deemed not to require an application for ethics approval. These included a questionnaire for teachers about school injuries; collection of population data on lifestyle, disease and disease course; and an optional online questionnaire to medical students. However the following SSCs were felt to need an application to an ethics panel: interviewing patients at a hospital clinic; interviewing of children at a school; questionnaire given to patients receiving insulin therapy; questionnaire to patients attending a local health centre; interviewing patients with chest pain at a cardiology clinic. Two other SSC's showed mixed opinion and would likely require an application to an ethics panel before these could be initiated.

The results of our Delphi technique highlighted to students the types of SSCs for which they would definitely need to apply for ethics approval ahead of time, and provided three options of simple data collection not requiring lengthy ethics approval. By publishing our findings in an SSC guidance document to the student body, the workload to staff from SSCs was reduced, students were informed where an application for ethics review and approval would be required, and examples were provided where approval need not be sought. Other medical schools can utilise this method to assist their students in the same way.

Hugh Sims-Williams

Department of Cardiology

North Bristol HealthCare Trust

Bristol, UK

E-mail: [email protected]

David Cahill

Centre of Medical Education

University of Bristol

Bristol, UK

Using videotaped vignettes to improve the teaching quality in child and adolescent psychiatry

Dear Sir

Despite the high frequency of mental disorders in children (10–20%), there is relatively low priority given to teaching child and adolescent psychiatry at university. In Europe, only 87% of medical schools reported teaching child and adolescent psychiatry and only 52% have an academic child and adolescent department (Kalman et al. 2000). Teaching programs need to be optimal and integrate all education strategies. The aim of our study was to evaluate the benefits of videotapes for teaching child and adolescent psychiatry to undergraduate and graduate medical students. Over a period of 1 year, a total of 107 students (41 undergraduates and 66 graduates) participated anonymously in the study. To be enrolled in the study, undergraduate students had to be in their second or thrid year, to have completed their regular thematic block or to have spent five half-days per week in the child and adolescent psychiatry unit (Robert Debré Hospital, Paris, France). After a session of courses supported by videotaped vignettes, students were asked to complete a questionnaire divided into three parts with a total of 12 questions dealing with the quality of video-based teaching, the improvement of learning, and the students' assessment of their own feelings when watching the videotapes.

We report that videos were didactically helpful and confer to medical students substantial benefits in their ability to understand and to learn child and adolescent psychiatry. Videos also modify students' perception about patients’ suffering and help students be more empathic with their patients. In addition, our results show that video-based teaching has more significant benefits for undergraduate medical students.

With the high frequency of children's mental health problems in the community and the low priority of child and adolescent psychiatry teaching programs in universities, video should become an important tool to offer a standard and efficient learning experience. Further studies on video-based teaching program need to be performed to assess the effect of video-based teaching on graduate students’ skills and knowledge retention.

Richard Delorme, Pauline Chaste, Isabelle Scheid

Samuel Cortese & Marie-Christine Mouren

Department of Child and Adolescent Psychiatry

APHP

Robert Debré Hospital

49 Boulevard Serurier

Paris 75019

France

E-mail: [email protected]