Letter to the Editor

Teaching chronic condition management to undergraduate medical students: Utilising the patient-as-teacher approach

Dear Sir

Improving care for those with chronic illness relies on health professionals understanding the difference between acute and chronic care approaches and utilising evidence-based principles of chronic care management. Ideally, this paradigm of thinking should be incorporated into teaching and learning at undergraduate student level with suggested applications to the care of people with chronic conditions across the health care sectors.

In 2008, University of Otago Wellington implemented a new component in the Primary Health Care and General Practice 5-week rotation for fourth-year medical students (in their first clinical year). This component included an interactive 2-hour teaching session with interprofessional teachers about the Wagner Chronic Care Model (Wagner 1998) with application to a case in a primary health care setting and a home visit by a student-pair to a person with chronic condition(s). One of the main objectives of the visit was that the person visited act as teacher to the student pair and students actively seek the experience of living with illness (Maudsley & Strivens 2000). Students were required as a pair to present to the class about the person they home visited and individually complete a reflective essay.

The academic staff evaluated the new programme by conducting a pre-course qualitative questionnaire and following the revised teaching programme and home-visit to the patient-as-teacher, evaluated the content of a student reflective essay. Analysis of the pre-course questionnaire showed that students knew little of the differences between acute and chronic care and the management of chronic conditions and held rather negative impressions about chronic conditions as well as how people experience them. The evaluation of reflective student essays written at the end of the course showed an increased student understanding of chronic conditions and their overall management in primary care. The students also gained a broad appreciation of how people experience chronic conditions including what troubles them, how they self manage and what supports their overall resilience. The evaluation endorsed the new programme including the value of the patient-as-teacher approach and teaching evidence-based chronic care management principles.

Eileen McKinlay, Lynn McBain & Ben Gray

Department of Primary Health Care and General Practice

School of Medicine and Health Sciences

University of Otago Wellington

Box 7343

Wellington South

Wellington 6242

New Zealand

Email: [email protected]

Enhancing confidence through process-oriented preparation

Dear Sir

Medical education is defined by standardized examinations requiring intense preparation for successful completion. While “personal learning habits” and “advice from other students” are important factors that affect student preparation for the USMLE Step 1 (Zhang et al. 2004), formal methods for addressing these factors and minimizing anxiety surrounding this exam are not integrated into most medical school curricula.

In an institutional self-review, 94% of students indicated that they were satisfied/very satisfied with their overall educational experience. However, only 74% were satisfied with the institution-sponsored academic guidance. While students praised the existing curriculum and knowledge-based preparation for Step 1, they desired earlier awareness and guidance on planning and preparation strategies.

In response to this student-generated critique, a five-part seminar series entitled, “Planning and Preparing for Success in Medical School” was integrated into the existing first- and second-year curriculum. It encourages process-oriented preparation by: (1) developing an early awareness of the transitions and challenges encountered in medical school, (2) encouraging early planning through organization, schedule generation, and upper-class student mentoring, and (3) emphasizing early preparation through resource gathering and comprehensive review.

Initial sessions focus on general concepts of transitioning and self-assessment, while final sessions focus on specific Step 1 preparation strategies, resource gathering, schedule generation, and structured self-review. Each session consists of a didactic presentation followed by an interactive forum in which upper-class students offer personal experiences and field questions from underclassmen. Open lines of communication are created between students and thereby foster rich mentoring opportunities.

After completing 2 years of the course, a profound impact on student confidence was observed. Over 84% of student-participants agreed/strongly agreed that the course was helpful in providing important guidance for Step 1 review. Students commented that the course provided “a great way to ease the potential stress of Step 1, [and feel] much more confident than before.” Students praised the interactive structure commenting that they “really appreciated the upperclassmen taking the time to guide [younger students] when [they] are confused and going through transitions.”

Of the numerous challenges that medical students face, the Step examinations are amongst the most significant. Through encouraging self-assessment, advocating structured preparation, and facilitating student mentorship, this process-oriented seminar series has significantly impacted student confidence.

Roy E Strowd

Ann Lambros

Wake Forest University

Medical Center Boulevard

Box 2409

Winston Salem, NC 27103, USA

Email: [email protected]

Development of a career pathways program to help students with specialty choices

Dear Sir

Specialty choice is a stress-inducing decision for many medical students. Although it has been shown that educational experiences and exposure to role models strongly influence career choice (Basco & Reigart 2001; Kirkham et al. 2006), most of the students do not gain this experience until Year III. This late exposure leaves students only a few months to plan their fourth-year rotations and ensure that they get appropriate experience in their preferred field. For these reasons, career planning should be an important component of undergraduate curricula.

To provide a comprehensive career advisement program, The Keck School of Medicine (KSOM) at the University of Southern California launched a Career Advising Pathways Program (CAPP) in 2005. The program goals were: broaden students’ exposure to a variety of disciplines in the first 2 years of medical school; assist students to identify career preferences earlier; provide opportunities for early experiences in an area of interest; and facilitate a mentoring relationship between students and faculty. The program consisted of three pathways: Academic Medicine, Clinical Specialist, and Community Health.

The goal of the Academic Medicine Pathway was to teach students about research and increase exposure to basic or clinical research studies. The Clinical Specialists Pathway was designed for students who are primarily interested in a career in clinical medicine. It was designed to expose students to the majority of medical specialties and assist students with the exploration of all career options. The Community Health Pathway was designed to expose students to community-based medical settings.

Student focus groups (N = 40) revealed that students found the program to be successful in heightening their awareness and getting them to start thinking about specialty choices earlier. The dominant and consistent theme that emerged was that all students could benefit from participating in the clinical specialist pathway. Based on this feedback, we restructured our program to better suit the needs of our learners. All students are now enrolled in the Clinical Specialist pathway and participate in a career seminar series lunchtime program, and AAMC CiM workshops. The academic medicine and the community health pathways have been converted into areas of emphasis/interest. Other areas of emphasis/interest are being developed and include global health, humanities, and business.

Maura Sullivan¹, Donna Elliott², Joel Schechter² & Clive Taylor²

¹Department of Surgery

Keck School of Medicine

University of Southern California

Los Angeles, CA, USA

Email: [email protected]

²Department of Educational Affairs

Keck School of Medicine

University of Southern California

Los Angeles, CA, USA

Assessing final-year medical students’ potential as doctors: OSCEs, Final MB and MTAS

Dear Sir

Final year medical student assessment needs to provide an assurance of clinical competence alongside the acquisition of appropriate knowledge, skills and attitude. Final MB examination is designed to test the competency of graduates, whilst UK Foundation year rotations are currently allocated through the MTAS system. In the latter, applicants are assigned a score mostly based on answers to vignette questions and partly on academic achievements. There are no published data investigating the ability of MTAS to identify more able candidates and to place them accordingly.

Achievement in OSCE examinations appears to be a good predictor of future performance as a doctor (Probert et al. 2003). Scoring schemes to stratify medical professionals and allocate placements might therefore be validated before their introduction against an OSCE.

With the premise that the most promising students (those with the greatest likelihood of becoming high-achieving doctors) deserve the best chance of getting their first-choice rotation, we ran a pilot study investigating the ability of OSCE to act as a validation system for MTAS scoring.

Thirty-five final year students volunteered to participate in a 10-station OSCE. Results from this exercise were compared with the academic and non-academic components of the MTAS score. We found no significant association between the OSCE total and MTAS total scores, OSCE total and MTAS vignette scores or OSCE total and MTAS academic scores.

Though suggestive, our pilot OSCE was not sufficiently powerful to confidently conclude that there is no association between MTAS and OSCE scores. However, we feel that a greater evidence base should be developed for identifying the legitimacy of MTAS-type systems, as their implementation becomes wider. Comparison with OSCE performance may be a useful tool, but we speculate that other markers, such as performance at F1, might be useful to correlate with MTAS scoring.

Barnaby D Hole

Foundation Year 2 Doctor

University of Bristol

St Michael's Hospital

Bristol BS2 8EG, UK

Email: [email protected]

David J Cahill

Deputy Director of Medical Education

University of Bristol

St Michael's Hospital

Bristol BS2 8EG, UK

Web-based patient simulation in a virtual department of urology in undergraduate education

Dear Sir

Standardized computer-based patient simulations as realized within the INMEDEA Simulator offer an interesting solution for the growing demand for case-based medical teaching and problem-solving approaches in medical schools. The INMEDEA Simulator is an interactive e-learning management system around a virtual hospital including a department of urology which can be accessed via the World Wide Web (http://www.inmedea-simulator.net). On this online platform virtual patient cases are presented, which have to be solved by medical students. In order to find the right diagnosis, students have to put themselves into the role of the treating physician, take a medical history, do a physical examination and perform all necessary laboratory, radiological, endoscopic and functional tests. Results of these investigations are illustrated by multimedia data including pictures and short films.

To get more familiar with this approach, virtual patient cases were included into our regular course of urology during the fourth year of medical school. Students were asked to prepare two patient cases on a voluntary basis at home prior the course. Both cases were then discussed in small groups of 6–8 students with a medical teacher. By means of an anonymous questionnaire and direct discussion with the students, it became evident to us that this teaching approach is very well accepted and serves as an excellent preparation for the regular course. Still, according to our believes, case-based learning should not completely substitute conventional teaching methods such as text book reading or classical lectures as they provide necessary theoretical background knowledge. Nevertheless, patient simulation clearly offers advantages as it puts students in a more active learning and problem-solving position which surely increases their motivation to learn.

To conclude, our teaching experience showed that virtual patient cases are a useful tool for undergraduate education. Still, as remarked critically by many students, virtual patients should not be used to replace contact to real patients or real teachers but rather serve as a preparation for students for their contact to real patients like flight simulators prepare pilots for real flights. In this perspective, we judge patient simulation as an excellent teaching method.

M. Horstmann

M. Renninger

J. Hennenlotter

C. C. Horstmann

A. Stenzl

Department of Urology

University of Tuebingen

Hoppe Seyler Str. 3

72 076 Tuebingen

Germany

Email: [email protected]

The educational environment of undergraduate students at the College of Health Sciences, University of Nairobi, Kenya

Dear Sir

This study aimed to determine students’ perceptions of the learning environment at the College of Health Sciences of the University of Nairobi in Kenya. A cross-section of undergraduate students in each of the four schools (Medicine, Pharmacy, Dentistry and Nursing) was recruited into the study. Ethical clearance was obtained from the Kenyatta National Hospital Ethics and Research Committee. A socio-demographic questionnaire (seeking information on age, gender, religion and marital status) and the self-administered Dundee Ready Education Environment Measure (DREEM) (Roff et al. 1997) were distributed to the students just before or immediately after their lectures.

A total of 543 out of the 953 students who were approached returned the questionnaires (response rate of 57.0%). However, this response rate varied across the four schools: 88.8%, 69.2%, 57.6% and 36.3% in the Schools of Nursing, Dentistry, Pharmacy and Medicine, respectively. There were no significant differences in the students’ socio-demographic profiles. The mean score on the DREEM for all the students combined was 86.9 (out of 200) and ranged from 82.5 to 91.2 across the schools.

The domain of learning was viewed negatively by 70.9% of the students, 4.6% perceived course organisers as being ‘abysmal’ while a further 12.3% thought course organisers needed retraining. On the other subscales, 40.6% had a positive academic self-perception, 63.0% felt that the academic atmosphere needed to be improved and 59.5% had a negative social perception.

More students in the School of Pharmacy than those in dentistry had a positive perception of learning (28.4% vs 11.7%) and a positive academic self-perception (30.1% vs 17.0%). A higher proportion of students in the School of Medicine (43.5%) than those in pharmacy (12.5%) considered their course organisers to be models. More pharmacy than medical students viewed the learning atmosphere (42.7% vs 28.5%) and social self-perception (47.3% vs 42.1%) positively.

These findings should be interpreted cautiously. The DREEM scores were not specific to any subject, but represented a cumulative score for all the students combined and each item was analyzed separately according to the specific responses. The overall mean score (43.5%) was lower than 59.0% reported in Nigeria (Roff et al. 2001) and suggested that students did not perceive their learning environment as being conducive. Although meaningful comparisons are not possible unless all the learning environments are controlled for, these Kenyan results call for an audit of the learning environment with a view to implementing and possibly adopting the increasingly popular Problem-Based Learning Model.

David M. Ndetei

Lincoln I. Khasakhala

Victoria Mutiso

Mary Kuria

Francisca Ongecha-Owuor

Donald A. Kokonya

University of Nairobi & Africa Mental Health Foundation (AMHF)

P.O. Box 48423-00100 Nairobi, Kenya

[email protected]; [email protected]

Clinical skills centres do not have to cost an arm and a leg

Dear Sir

The UNSW undergraduate medicine program, with its large and increasing student numbers, has strived to develop a sustainable and inexpensive strategy to the teaching of clinical and communication skills to medical students in their initial years of training. The strategy used alternating weekly campus-based ‘in vitro’ sessions with hospital-based ‘in vivo’ sessions. The campus sessions in Phase 1 (years 1 and 2) are based on a peer-examination and peer-interviewing approach. The sessions focus on history taking, basic examination and procedural skills and a wide range of communication issues. The maximum group size is 30 students and they are supervised jointly by a clinical tutor and a communications tutor. In follow-up hospital sessions, students in groups of seven can practice the skills directly with patients under the supervision of a clinical tutor.

To evaluate the clinical and communication course from the students’ point of view, we invited all Phase 1 students (n = 467) to complete a questionnaire and 303 (65%) responded.

The survey results indicated that in hospital sessions, opportunities to practise with patients were limited, whereas campus teaching allowed students to practice freely on each other, with the safety of being able to make mistakes in front of their peers; the teaching was also structured and consistent. The combination of campus and hospital sessions resulted in a majority of students feeling they had frequent opportunities to practice their skills with peers and patients and develop confidence.

Hospital and campus sessions were equally likely to provide opportunities to practise communication skills but predictably, hospital sessions were seen more often as relevant to communicating with patients. This was in spite of communication skills training in hospitals being limited by time and opportunity constraints. Campus sessions attempted to compensate for this by introducing more complex and varied situations for communication exercises. However, some students identified some of this material – particularly cultural and ethical perspectives – as excessive and irrelevant.

We are satisfied that the majority of students feel that the campus and hospital sessions together provide complementary opportunities to develop both clinical and communication skills. We believe that the peer-examination approach is a viable and sustainable approach for setting up a clinical skills training centre and is an attractive option given its modest resource requirements.

Edna Koritschoner, Chinthaka Balasooriya & Leah Bloomfield

School of Public Health and Community Medicine

University of New South Wales

Sydney

NSW 2052

Australia

Email: [email protected]

Mentorship in medicine: Potential implications beyond the mentee–mentor relationship

Dear Sir,

We read with interest the recent article in Medical Teacher in which potential benefits and disadvantages of mentoring were reviewed (Taherian & Shekarchian 2008). Although physician mentoring has many proposed benefits for both mentee and mentor, it may have benefits for the medical specialty itself and the population it serves. We are interested in the role of mentoring to influence the distribution of physicians in the workforce, especially in those areas with greatest shortage. We received ethics approval to survey the views of Canadian post-graduate training Program Directors (PDs) on mentorship. Names were obtained from the Canadian Residency Matching Service (CaRMS) directory of training programs (http://www.carms.ca). PDs were e-mailed a link to an internet survey (http://www.surveymonkey.com). Two reminders were e-mailed to non-responders at three-week intervals before the survey was closed. A ‘mentorship program’ was defined as a formal or informal program within the training curriculum with opportunities for establishment of faculty-trainee mentoring relationships. PDs were surveyed on the need for more physicians to pursue academic careers, leadership positions, careers in underserviced areas and whether a mentorship program had the potential to increase the number of graduating physicians who ultimately pursued careers in these three areas.

One hundred and ninetynine of 344 PDs responded to the survey for a response rate of 58%. Fortynine percent of PDs wanted more post-graduate trainees pursue academic careers, 56% wanted more to pursue leadership positions and 40% wanted more to pursue careers in underserviced areas. Overall, the vast majority (85%) felt that a mentorship program had the potential to increase the number of physicians who ultimately pursued careers in these areas.

It is important to continue to develop strategies to optimally nurture our post-graduate trainees. Future studies on mentorship should not only evaluate the direct benefits of mentoring to mentees and mentors but also rigorously evaluate the potential for mentoring to generate physicians in areas where they are often in short supply, including academia, leadership positions and underserviced areas.

Andrea Donovan and Jeff Donovan

Department of Medical Imaging

Department of Medicine (Dermatology)

Sunnybrook Health Sciences Centre

University of Toronto

2075 Bayview Avenue

Toronto, Canada, M4N 3M5

Email: [email protected]