LETTERS TO THE EDITOR

Patients’ attitudes towards medical student ‘clerking’ in Hong Kong

Dear Sir

The conduction of history-taking and physical examination (or ‘clerking’) on real-life patients is an important component in clinical teaching. Previous studies have reported on patients’ experience with medical students in out-patient clinics but there has been little discussion on the experience of in-hospital patients. A structured questionnaire survey was conducted on a convenience sample of 225 adult in-hospital patients at our institution to investigate their attitudes towards student clerking. While the majority (70.2%) of patients considered it their responsibility to participate in medical education, most (88.0%) would still consider prior consent mandatory on individual occasions irrespective of their gender, age and education level. Although the experience with clerking was reported to be ‘pleasant’ or ‘very pleasant’ in 78.5% of patients, up to 60% of patients did report disturbance of sleep or feelings of discomfort, and prior consent was not obtained in 12.0% of cases. We also found that 71% of patients would accept up to three clerking sessions per day while 56% would not tolerate more than three students per session. The patients’ past experience with clerking was found to significant influence their willingness to be clerked again, and those with less satisfactory experience with medical students were less likely to attend a teaching hospital in the future.

Universities and medical schools are entrusted to create the proper environment for patient participation in medical education. Although medical students have the right to clinical education, ‘the obligation to fulfill this right rests with the medical universities and not on the patients’ ( Waterbury 2001). Students should be reminded that patient's consent to clerking should not be presumed even at teaching hospitals. Students should also realize their potential impact on patients’ future participation in teaching activities and their choice of medical care institution. Concerted effort should be made during the organization and conduction of clinical teaching to ensure patient autonomy and comfort.

Dr Gilberto Ka Kit Leung

Samuel Shung Kay Chan

Sai Tim Lam

Department of Surgery

Li Ka Shing Faculty of Medicine

The University of Hong Kong

Queen Mary Hospital

Hong Kong

Medical students’ knowledge of osteoporosis

Dear Sir

Osteoporosis is a major public health problem in many countries. Educating healthcare providers about osteoporosis may play a pivotal role in improving osteoporosis management. However, there are very few studies on the physicians’ level of knowledge on this matter ( Taylor et al. 2001; Jaglal et al. 2003). This has resulted in doubts regarding the osteoporosis knowledge of students trained to be medical doctors but no studies have been found on this matter. This study is constructed to establish whether or not medical students who will become general practitioners acquired the necessary knowledge during their education and to assess their readiness to assume the role of educator related to this disease.

A total of 375 medical students from each grade were asked to fill in a questionnaire about osteoporosis.

Of the respondents, 98.8% defined osteoporosis correctly (there were no differences between classes, p > 0.05). Only 0.3% of the medical students who completed the questionnaire answered all the questions on the risk factors for osteoporosis correctly. Meanwhile, 70.9% of the students knew the methods to establish the diagnosis of osteoporosis. The fact that supplementary medications in addition to calcium are needed for the management of osteoporosis was known by 45.9% of the medical students. With 10.7%, very few students knew that osteoporosis is directly responsible of hip fractures. There were statistically significant differences in knowing the symptoms, osteoporosis is responsible of hip fractures and the risk factors for osteoporosis (knowing ratio in class of 4–6 > class of 1–3) (p < 0.05).

The results of the present study show that medical students knew the definition of osteoporosis but their knowledge on risk factors, complications and preventive measures were insufficient.

The aim of studies addressing the knowledge of osteoporosis among the general population and students is to obtain the results of raising the population's consciousness with regard to the risk factors and preventive measures. However, there are very few studies assessing the knowledge on osteoporosis of healthcare professionals who are important for the management and prevention of osteoporosis ( Taylor et al. 2001; Jaglal et al. 2003). A high proportion of general practitioners reported that they did not have sufficient knowledge on osteoporosis during their undergraduate education ( Taylor et al. 2001). Family physicians also expressed a wish to get more information on the risk factors and management ( Jaglal et al. 2003). The current study revealed that there are gaps among healthcare providers.

Knowing the risk factors and planning of the preventive measures against these risk factors are far more important than treating osteoporosis. Changes in undergraduate medical curriculum and community-oriented teaching should lead to greater awareness of the public health impact of osteoporosis. During their medical education, medical students should be furnished with necessary information on risk factors for osteoporosis and preventive measures that are applicable to the community and this knowledge should allow them to plan effective ways of disseminating information.

Sibel Eyigor, MD

Assistant Professor

Ege University Faculty of Medicine Physical Therapy and

Rehabilitation Dept, 35100 Bornova-Izmir-Turkey

[email protected]

Hale Karapolat, MD

Ege University Faculty of Medicine Physical Therapy and

Rehabilitation Dept, 35100 Bornova-Izmir-Turkey

Berrin Durmaz, MD, Prof

Ege University Faculty of Medicine Physical Therapy and

Rehabilitation Dept, 35100 Bornova-Izmir-Turkey

Presentation

This study was presented in a poster format at the 4th World Congress of the International Society of Physical and Rehabilitation Medicine, in Seoul, Korea between 10th and 14th June 2007.

Modern pathology teaching and the internet

Dear Sir

Pathology teaching in medical schools has decreased in recent years. This is partly due to the shift away from discipline-based teaching in medical curriculae but also as a result of additional pressures, such as of lack of time and resources, felt by Pathology teachers ( Domizio & Wilkinson 2006).

The internet is an important learning tool for students of the ‘Net Generation’ (Sandars & Morrison 2007) and it has recently been suggested that watching video clips via eLearning facilitates learning ( Romanov & Nevgi 2007). E-Learning is an innovative technology which can support and enrich medical education ( Smothers et al. 2008)

We were interested to survey the medical educational content of the popular online video sharing site YouTube (www.youtube.com) and assess whether it could contribute to both undergraduate and postgraduate Pathology teaching. We performed a search (21/04/08) using the terms ‘Histology’ and ‘Histopathology’.

Histology yielded 204 hits of which 99 (49%) contained relevant information consisting of lectures and descriptions of histology slides. The second largest group of results returned consisted of 69 videos (34%) which were not thought to be useful for educational purposes because they were either in a language other than English, of poor quality, were not directly relevant to the search terms or concentrated on animal histology. The remaining 36 (17%) were either promotional material or ‘Spoofs’ on histology classes; these were not though to be useful as educational material.

Histopathology yielded 551 videos. Surprisingly, all of these appeared relevant (100%). These videos consisted of descriptions of slides and explanations of disease processes.

To survey the content of these videos we selected 20 random videos which were examined by a senior Pathologist (Herrington). We were interested to see if the videos were accurate, whether they contained any obvious mistakes, and whether they were useful for undergraduate or postgraduate Pathology teaching:

The selected videos are generally informative. The majority provided useful information using good examples of the disorders being described. There was a tendency to use rather colloquial language: whilst this aids understanding on a publicly available website, it detracts to some extent from the professional educational value of the material. Some of the examples viewed were of rare disorders e.g. adrenoleukodystrophy and pancreatic amyloidosis. These are perhaps less relevant to undergraduate education, although they do illustrate pathological principles well.

We have identified YouTube as an informative and accurate source of histopathology learning for both undergraduates and postgraduates. It is clear that caution must be advised with regards to the level of medical terminology used and the rarity of the disorders described in some cases. Despite this, the authors feel it remains a useful learning resource - particularly if used in combination with other learning materials.

In addition, during our examination of YouTube it also became apparent that a number of autopsies or post mortems were present on the site. Although autopsies have been shown in the popular media (Von Hagen 2006) it still came as a surprise to the authors that such material was available. It would seem unlikely that informed consent has been obtained for such material to be posted and its educational value is debatable.

Andrew Wood

[email protected]

Kate Struthers

[email protected]

Simon Herrington

[email protected]

Bute Medical Building

University of St Andrews, UK

Improving rational prescribing by medical students

Dear Sir

Given that most consultations end with doctors writing a prescription, it is essential that doctors prescribe drugs effectively and safely. However, despite recognition of the importance of rational prescribing, the teaching of pharmacotherapy to undergraduate medical students is still unsatisfactory. Many medical students feel under-prepared to take on prescribing responsibilities after graduation, and the prescribing skills of students and residents are often poor (Richir 2008).

Indeed, in many curricula, clinical teaching is still mainly centred on symptoms and diagnosis, and little or no time is given to the principles of drug treatment or to the process of therapeutic decision-making. Therefore, it is not surprising that students find themselves uncertain about the choice of drug therapy. A pilot study performed in all eight medical facilities in the Netherlands showed that medical students base their drug choice mainly on the examples given by their medical teachers.

So, how can medical students learn to prescribe drug treatments rationally. Firstly, medical teachers should appreciate that medical students tend to copy their drug choices, and for this reason they should explain to their students how they arrived at a specific drug choice. Even better, they should ask students how they arrived at this choice. Secondly, teachers should provide students with a method to help them choose and prescribe drugs in a systematic and rational manner. The WHO 6-step model presented in the Guide to Good Prescribing is such a model that has proven effective (De Vries 1994). For example, it has recently been shown that application of this 6-step model leads to the use of more rational prescribing modalities by medical students during their clinical clerkship in internal medicine (Richir 2008).

In conclusion, because the aim of medical training is to generate competent medical doctors who are able to prescribe drugs rationally, it is essential to ask medical students to justify their drug choice instead of merely asking them which drug they should prescribe.

Jelle Tichelaar

Theo PGM de Vries

Milan C Richir

Department of Clinical Pharmacology and Pharmacy

VU University Medical Center

Amsterdam

The Netherlands

Implementation of the Bologna two-cycle system in medical education – The students’ view

Dear Sir

There has been considerable discussion on the Bologna Process: The effort to harmonize European higher education. The implementation of a two-cycle structure is one of the most controversial aspects of the Bologna Process in Medicine.

We applaud the initiative taken by Patrício et al. (2008) in a recent issue to provide an overview of the present state of the implementation process.

We would like to provide some comments from the students’ point of view.

In 2004, medical students were the first stakeholders to issue a statement on the Bologna Process ( Onur et al. 2005). Back then, we raised our concerns regarding the implementation of a two-cycle structure in medicine. Three years later we wrote a second statement to comment on the progress that had been made in the field of medicine (IFMSA and EMSA 2007a), in particular with regards to the implementation of the two-cycle structure. European medical students agreed that the implementation of such structure in medicine is feasible, and addressed several concerns that required immediate and coordinated efforts from all stakeholders in order to avoid the potential negative impacts of this structure on several areas of the medical studies and profession. In the meantime other organizations and stakeholders had also issued policy statements: AMEE, CPME, WFME, AMSE and WHO-Europe (see Patrício et al. 2008 for an excellent overview).

At the time, these signs of cooperation between all stakeholders in the European medical education community seemed to channel the implementation of the Bologna Process.

Eight years after the initial document we are concerned to read Patrício's findings on the implementation of the Bologna Process. Lack of knowledge at governmental and university level is seriously hampering the achievement of Bologna's common goals and seems to hinder the harmonization of medical education. The great disparity among countries is worrying and is not beneficial for the development of better medical education.

We still believe that the implementation of the two-cycle structure in medicine is possible. However, we must be aware of possible negative consequences if implemented without proper consideration and care.

We share the analysis by Patrício et al. that many countries see the two-cycle structure as a retrogressive step that might strengthen the unhelpful traditional division between the basic sciences and clinical sciences. Therefore, in order to achieve harmonization of medical education in Europe we deem it necessary to agree on core learning outcomes to be achieved by graduation. These common core outcomes would constitute the European Core Curriculum in accordance with relevant European regulations (i.e. directive 2005/36/EC). We consider early integration of basic and clinical sciences essential in producing better doctors. Local academic traditions and priorities should however be encouraged and these additional curricular elements should be clearly defined. We have published our suggestions for a European Core Curriculum before in your journal (IFMSA and EMSA et al. 2007b).

We feel that the two-cycle structure should not be an obstacle to improve, develop and reform medical curricula. In itself the Bologna Process does neither contradict nor negatively impact medical curricula. It is rather its inconsiderate implementation that may lead to adverse effects on educational outcomes and patient safety. Increased engagement of all stakeholders is essential to ensure that the quality of medical education within Europe, and consequentially patient safety, does not suffer. Unwillingness to discuss possible implementation of the two-cycle structure in medicine is already a failure in itself that would seriously hinder harmonization of medical curricula in Europe and would weaken the eventual implementation of such structure.

As medical students who strive to improve the quality of our education and our competence as tomorrow's doctors, we encourage all stakeholders to use our concerns and suggestions as a basis for discussion. We strongly believe in the benefits of this effort, based on the understanding that the ultimate goal of medical education is to improve the health of our citizens.

Robbert Duvivier

Jan Hilgers

Nikos Davaris

Daniel Rodriguez Muñoz

Standing Committee on Medical Education, International Federation of Medical Students’ Associations

[email protected]