Letter to the Editor

A new structured work observation programme for prospective medical students

Dear Sir

There is a paucity of comprehensive guidelines for the work experience programmes which may potentially risk breach in patient confidentiality, students being exposed to physical and psychological hazards and the patient's basic rights to privacy being threatened. We devised a structured work observation programme based on the guidelines issued by professional bodies such as GMC, BMA and the Royal colleges.

Fifty-seven sixth form students were accepted for the work observation programme between 2002 and 2003. A formal programme of events included attendance to outpatient clinics, operating theatre, pharmacy and pathology departments. Responsibility for consent and confidentiality was predominantly with the consultants in each area and this was agreed with them. A retrospective postal questionnaire was conducted to determine the opinion of the participants.

Thirty-two female and 15 male students attended the programme. Seventy percent of the questionnaires were returned. Eighty percent of the students felt the programme strengthened their intention to do medicine, 17% felt there was no impact, 93% of the students felt the programme provided good insight into medicine as a career, 68% of students who attended the programme have entered medical school, 19% failed to obtain adequate A level grades and 13% decided not to study medicine subsequent to A level grades.

Recruitment and retention are important issues for the NHS (Parkhouse 1997). Several factors were seen as advantages to the work observation programme (Rushton 1993): a proper programme could be offered to all prospective students and so remove the inequality of access caused by the ‘friends and family’ system. The structured work observation programme was highly appreciated by sixth form students and the majority obtained successful medical school placement. Prospective medical students should get realistic experience. We feel that such a programme facilitates the entrance of students into medical school and should be more widely available.

P. Sanjay & Irshad Shaikh

Department of Surgery, Queen Margaret Hospital Dunfermline, UK

E-mails: [email protected] and [email protected]

Ray Rivron

Department of ENT, Royal Glamorgan Hospital, Llantrisant Wales, UK

Alan Woodward

Department of Surgery, Royal Glamorgan Hospital Llantrisant, Wales, UK

Should the educational supervisor be medically qualified? Inviting a debate

Dear Sir

The emerging evidence on educational supervision (ES), although small, points towards specific personal qualities that are required to become an effective educational supervisor (Kilminster et al. 2007). Interestingly, none of the qualities described like commitment, motivation, counselling and listening skills and self-awareness are in any significant way related to the medical knowledge or technical skills of the trainer\supervisor. If this data is correct, and there is no reason to suspect otherwise, it raises the question – should the educational supervisor be medically qualified? It also brings up a fundamental issue about ES; whether the process is a generic educational task or the one that requires the supervisor to have gone through the same or similar medical training to the trainees.

In certain areas of Australia the challenge has been taken on, albeit in a limited form (MEO 2007). Some of the duties of the educational supervisor have been allocated to educationalists with no medical qualifications. The post-holder (medical educational officer) works closely with the director of medical education to develop, implement and evaluate continuing medical education activities in junior trainees by applying their knowledge of adult learning principles. They also facilitate the application of an assessment framework, and participate in providing formative feedback. The practice appears to be effective (personal communication) though the literature in support is sparse.

To take the issue further we conducted a local survey among our trainees. Among the 50 trainees who responded, 76% felt that supervisors should have a medical background. Among the reasons given were the perception that a pure educationalist would fall short on conducting appraisal 63% (n=24), assessment 80% (n=32), but mostly difficulty in offering career counselling. Although the majority (90%) felt that a pure educationalist would have good listening and communication skills, these would not compensate for the difficulties in the other areas. Nonetheless, most trainees acknowledged that in an ideal situation the educational supervisor should also be educationally qualified.

The demand for effective ES has been one of the key challenges in postgraduate medical education. ES is an explicit professional responsibility with well-defined objectives and when discharged effectively should make considerable difference to training. Since only a small number of NHS consultants acting as educational supervisors have the educational qualification for the job, the question is whether having pure educationalists participating in ES at ground level should be the way forward. I welcome a debate on the matter.

Aza Abdulla

Consultant Physician, Training Programme Director – CMT

Princess Royal University Hospital

Bromley Hospitals NHS Trust

Orpington

Kent BR6 8ND

UK

Email: [email protected]

Impulsive response style in undergraduate medical students: Implications for learning and future professional practice

Dear Sir

Extensive research in young children and college students has identified an association between lowered academic achievement and a high impulsive response style. There are individual differences in response styles, with a continuum from thoughtlessly reactive (impulsive) to reflective to excessively preoccupied. This response style influences the individual's behaviour in a variety of contexts, both academic and practical. It has also been suggested that high impulsivity may be associated with impaired clinical performance (Moulton et al. 2007).

We have recently become interested in whether the response style of undergraduate medical students has a similar impact on their behaviour, but we have found no studies of this area within the medical education literature in undergraduate medical students. Our first step, therefore, was to establish how we could identify the impulsive and reflective response styles in a population of undergraduate medical students. We used the validated self-report Reflective Activity Scale (RAS) with 276 first- and second-year undergraduate medical students (Courbasson 2006). The mean RAS scores of our population were broadly similar to those found in the previous study on young Canadian college students.

We hope that medical educationalists will be stimulated to carry out further research into this important area. The RAS could be used in a similar way to learning style inventories, in that the RAS can allow an individual's response style profile to be compared with the population profile. Further work is needed to determine the degree of association of impulsive response style with academic and, more importantly, clinical performance. Also, further work is recommended to develop and evaluate educational interventions that are designed to modify impulsive response styles, similar to the extensive work that has been performed in young children and college students. We are keen to hear from others who are interested in this area.

John Sandars

Senior Lecturer in Community Based Education

Medical Education Unit

Level 7 Worsley Building

The University of Leeds

Leeds LS2 9JT, UK

Email: [email protected]

Matthew Homer

Medical Education Unit

Level 7 Worsley Building

The University of Leeds

Leeds LS2 9JT, UK

Tel: [phone]

In the university morgue: Insight into factors modifying students’ vulnerability

Dear Sir

The first experience in the autopsy room has frequently been described as a potential stressful event in the education of the medical students (O’Carrol et al. 2004; Papadodima et al. 2008). In the National University of Athens, Greece, medical students attend a 5-day compulsory practical session on forensic medicine in the sixth year of their education. In our study, 304 students (in the academic year 2005–2006) were asked to fill in two questionnaires at the beginning and the end of the course. Three scores were created, measuring physical symptoms, psychological symptoms and feelings towards autopsy. Students were also asked about sociodemographic and academic features, stereotypes, concerns, coping strategies and attitudes so that the factors associated with more pronounced physical and psychological reactions could be identified.

Female gender was found to be associated with psychological symptoms (p < 0.001); on the contrary, inclination to surgery was a physically (p = 0.027) and psychologically (p = 0.037) protective factor. Fear of death was a significant aggravating factor (p < 0.001). The negative stereotype perceiving forensic doctors as persons of a peculiar character was associated with negative feelings towards autopsy (p = 0.006). On the other hand, the rather positive stereotype concerning the beneficial effect of time was associated with positive feelings (p = 0.018) and less intense symptoms (physical, p = 0.021 and psychological p < 0.001). Passive coping strategies during the dissection (irrelevant thoughts and shutting the eyes) were associated with physical (p = 0.025 and 0.001, respectively) and psychological vulnerability (p = 0.005 and <0.001, respectively). Among concerns about autopsy, view of the dead face (p = 0.005) and the sounds of electric sew (p = 0.001) mainly predicted the psychological vulnerability. Attendance of theoretical forensic courses and participation in gross anatomy courses exhibited only a borderline protective effect.

In conclusion, vulnerability of students in the autopsy room integrates a host of factors, both mutable and immutable. Questions on the key predictors of vulnerability may offer potential for screening and prevention.

Stavroula Papadodima

Theodoros Sergentanis

Emmanouil Sakelliadis

Dimitrios Vlachodimitropoulos

Chara Spiliopoulou

Forensic Medicine and Toxicology

Medical School, University of Athens, Greece

Email: [email protected]

Lack of biases in the MMI

Dear Sir

Selecting medical students is a high-stakes process that traditionally focuses on academic achievement. Unfortunately, this can discriminate against candidates from disadvantaged areas. To help overcome this, many medical schools use interview formats that involve one candidate and one or more interviewers. However, these formats experience problems of interviewer bias as well as poor reliability and validity.

Fairness is important in selection and instruments used for making decisions must not discriminate. Consequently, along with many medical schools, we implemented the more evidence-based multiple-mini interviews (MMI) (Eva et al. 2004) to assess non-cognitive attributes. This was particularly important as our School is situated in an outer suburban area of a large city which experiences shortages of medical practitioners, higher disease incidence, and lower socioeconomic status (SES).

Our MMI comprised nine stations, each with one trained interviewer. Two scores are given at each station using 5-point scales, with anchors ranging from poor to outstanding. The questions are specific to each station.

We analysed MMI stations used in 2006. Approximately 2300 candidates applied for 100 places and 345 were interviewed. The majority of interviewees were school leavers aged 17 and 18 years. There were 132 (49.1%) from the local lower SES region. Just over half (53.2%) of the interviewees were females.

Analysis revealed a high degree of internal consistency (Cronbach's α = 0.83). The overall scores and individual stations were compared by t-tests and Rasch Differential Item Functioning (DIF).

There was no statistically significant difference in the total MMI score between males and females (65.8 (SE = 0.85) and 67.1 (SE = 0.70), respectively; p = 0.23) and SES (66.1 (SE = 0.70) low SES and 66.7 (SE = 0.83) for others; p = 0.58). There were also no statistically significant differences between the individual station scores based on either gender or SES.

We repeated the analysis using the Rasch approach. Items demonstrate DIF when candidates who have the same score on an underlying construct respond to the item in a different way because of their membership in a particular group. Rasch analysis did not reveal any DIF.

This study demonstrates that neither gender nor socioeconomic status have a significant impact on performance in the MMI at this institution. While the MMI, like other interviews, may be subject to other biases, the current research lends support to the MMI methodology being fairer and less discriminatory in selection.

Ian Wilson, David Harding, and Neville Yeomans

School of Medicine

University of Western Sydney

Locked Bag 1797

Penrith South DC

NSW 1797

Australia

[email protected]

Barbara Griffin

Department of Psychology

MacQuarie University

North Ryde, NSW 2109

Australia

How doctors learn? A study of the learning needs and learning methods of doctors in a teaching hospital

Dear Sir

Doctors of different grades have different motivations to learn and they use different resources to inform their learning. Physicians traditionally favoured medical journals for case-specific information, textbooks for general information, while consulting medical colleagues was also an important resource (Verhoeven et al. 1995). Technological advances have resulted in many highly accessible learning resources, but are they familiar to doctors of all grades? Many literatures on the use of medical learning resources were published prior to the recent expansion of electronic data. How do currently practicing doctors learn?

We undertook a study to identify how learning needs and motivations differ with doctor's experience and to identify the resources employed to facilitate learning.

We submitted a questionnaire to five grades of doctors at education meetings in a teaching hospital in Limerick, Ireland. A wide range of learning methods and influences were inquired of and participants were asked to rate the different learning resources from 1 (lowest rating) to 5 (highest rating).

The most influential modes of learning for all doctors (n = 98) included working with consultants, working with peers and preparing for examinations (all with median rating = 5), while textbooks, personal research, international and hospital conferences, teaching junior doctors, preparing lectures and the internet also rated highly (all with median = 4). The least influential resources reported were pharmaceutical representatives and pharmaceutical promotion material (all with median rating = 2). As learning resources, senior doctors are more influenced by medical journals, audit and preparing and delivering lectures and case presentations. Junior doctors are more influenced by textbooks, by non-professional material and by free medical newspapers and magazines.

While our results represent reported preferences from one Irish hospital only, doctors of all grades reported learning most by working with peers and senior colleagues. This highlights the importance of clinical, on-the-job teaching. The teaching ward round, complete with ruminations on medicine and life, may be the most important component of medical education.

David P. Gallagher

Caroline White

James O’Hare

Department of Medicine

Mid-Western Regional Hospital

Limerick

Ireland

[email protected]

Equipping consultants as medical educators: A potentially large undertaking

Dear Sir

‘A Guide to Postgraduate Specialty Training in the UK’ (The Gold Guide) recommends that all consultants involved in the recruitment, training, assessment and appraisal of doctors should receive formal training in each task they undertake (Department of Health 2007). The Gold Guide also states that educational and clinical supervisors should be able to ‘demonstrate their competence in educational appraisal and feedback and in assessment methods’. In addition, educational supervisors should have an ‘understanding of educational theory and practical educational techniques’ acquired through recognized training programmes. Postgraduate Medical Education and Training Board (PMETB) has also developed standards for trainers as part of its quality assurance statutory obligations (PMETB 2008).

An electronic survey using, an on-line questionnaire, was conducted by the postgraduate deanery in Mersey to establish which educational skills and competencies consultants had already achieved and to identify areas of further training need. Respondents provided details of educational qualifications gained, training undertaken and any training perceived to be required. An opportunity for free-text comments relating to these issues was also offered.

The questionnaire was completed by 466 consultants (27% of the consultant workforce in Mersey Deanery). Seventy percent had recently completed equal opportunity and diversity training, 60% work plac-based assessment and e-Portfolio training, and 26% had attended Training the Trainers courses. Fifty-three (11%) respondents had also gained a formal qualification in postgraduate medical education. A theme highlighted in the free-text responses was the issue of having to balance providing a service with attending training events to develop their own educational competencies, despite, in theory, having study time made available to them by their Trust.

The findings of this survey have formed the basis of a database of consultant's educational training in the Deanery. The possible gaps in some consultants training indicated by the survey may be an underestimate. There is an urgent need to fill these gaps which may be no small undertaking. Mersey Deanery has now put a strategy in place to increase the availability and uptake of educational training for consultants. This includes courses for supervisors run in collaboration with the Royal College of Physicians, an accreditation process for experienced trainers and training for trainees so that they achieve the competencies during their training.

Nigel Shaw

Ida Ryland

Margaret Bamforth

Vish Kini

Jim Higgins

David Graham

1st Floor

Regatta Place

Brunswick Business Park

Summers Road

Liverpool, L3 4BL, UK

Email: [email protected]

The role of desire and expectations from medicine in students’ well-being

Dear Sir

Medical school, often blamed as a period of significant psychological distress for all medical students, may actually be a stressor just for the reluctant students. Despite the reported considerable high prevalence of psychological distress in medical students, not much is known about the effect of the decision process to attend medical school on this psychological process. Different factors can be significant in the decision to attend medical school such as parental influence, anticipated income or prestige (Benbassat & Baumal 2007). What is the role of desire and expectations from medicine in students’ well-being? What can be done for the reluctant students in medical faculties? We believe that educators and medical faculties must know their student unwillingness from the beginning of first year in order not to be blamed as a stressor. Some authors claim that the main ‘filter’ which defines who will enter medical school is not the medical school admission process, but rather an individual's decision to apply for admission (Benbassat & Baumal 2007).

There are other factors causing stress other than the individual's decision in different countries. Because of the high proportion of young people in the country's population, university education is very competitive in Turkey. For admission into medical schools, the student needs to be qualified in the government held Student Selection Exam (ÖSS). Because of this competition, students sometimes choose medical education unwillingly. Besides, some students are not mature enough to asses realistically and objectively their own abilities, motives and future aim (Benbassat & Baumal 2007). As educators, should we find a way to guide these students or should we let them continue their education reluctantly? Some authors suggest disseminating information on the requirements for medical training in general, working hours, quality of the life of doctors, the most common causes of dissatisfaction and burn-out in order to help applicants in making an informed decision (Benbassat & Baumal 2007). However, many would still desire to be a doctor strongly enough despite all the negative aspects of this career. We believe that our main responsibility is supporting the unsure and reluctant minds by teaching the magic of medicine.

Nazan Karaoglu & Muzaffer Seker

Meram Medical Faculty

Department of Medical Education and Informatics

Selcuk University

Konya, Turkey

E-mail: [email protected]