Letters to the Editor

Using role play for teaching conflict management

Dear Sir

Communication skills are gaining increasing attention; however, the opportunities for training as well as the faculty development are limited, especially in medical schools in the Middle East. The Medical Education Unit at the King Faisal University, Dammam, organized a workshop on ‘Communication skills in health professional education’ to sensitize 168 participants from medical, dental and nursing – faculty, residents and final year students. I share my experience as a faculty, in organizing a session on conflict management utilizing the role play successfully. The management of conflict between the chairperson and the faculty member is a sensitive area, since they serve as role model for the rest. Moreover, didactic teaching would be ineffective if not useless.

A month before the workshop, I picked up two potential participants for the role play. Both were residents and had evidenced acting talent in the department of community medicine. I wrote the script for the role play. The theme was interaction between the chairperson and a faculty member, who reports to the chairperson after attending a workshop on medical education. The chairperson is a tough guy. The junior is enthusiastic but not sure how to motivate the boss for implementing new ideas.

The role play included two scenes of 5 min each. In the first scene, the interaction begins with a neutral note, but soon the blame game starts and gets vitiated till it completely breaks at the end leaving both the parties totally frustrated. In contrast, during the second scene, the junior faculty follows good principles of conflict management, and completely changes the mood of the chairperson. He boosts the ego of the chairperson, assures him of his unconditional support and gradually ‘sells’ the new ideas gained during the workshop. This time, the chairperson is a converted person and offers full support for the junior in implementing new ideas.

At the end of the second scene, I debriefed the participants, who came out with all the principles of good conflict management. The feedback received from the participants revealed that they thoroughly enjoyed the role play. The message was loud and clear. The role play could be implemented successfully, when we need to teach the attitudes with heightened interaction, instead of didactic presentation.

B.V. Adkoli

King Fahd Hospital of the University

Administrative Building

P.O Box No. 2208, Al-Khobar

Saudi Arabia

E-mail: [email protected]

Assessing patient safety competencies during clerkship: A new experience with OSCE

Dear Sir

Recently, patient safety (PS) concerns have called the attention of medical educators, mainly during postgraduate training and medical practice improving programs. Previous studies described that the first encounter with medical errors (ME) for most physicians occurred when they were students during clinical rotations. Clerkship is considered the ideal moment to incorporate PS competencies; however, very few studies have described this experience.

In a comprehensive study, White et al. (2008) described the attitudes and experiences of 629 medical students and 509 postgraduate trainees regarding ME and their disclosure to patients. Those authors found that 79% of the students reported involvement with ME, predominantly minor errors and near misses. Only 35% of those students reported previous education or training in ME disclosure. Martinez and Lo (2008), in their pioneer study analyzing exclusively the students’ experience with ME, described that 76% of the students reported having witnessed a medical error and 18% reported having committed a ME during their clinical training. Unfortunately, many of them stated having witnessed residents and/or attending physicians occulting the ME from patients and medical staff coordinators. Both findings reinforce the necessity to teach, train, and assess medical students regarding PS competencies, providing them with adequate role-models to be followed.

In 2007, a PS program was first introduced in the clerkship of the University of São Paulo School of Medicine (Brazil). An OSCE with one station related to PS competencies was applied. The PS station included three domains: medical error recognition/disclosure, physician-patient relationship (PPR), and humanistic behaviors. A total of 95 fifth-year medical students applied to the OSCE. Medical error domain presented the lowest mean scores when compared to PPR and humanism domains (p < 0.05). Less than 60% of the students asked for apology after the occurrence of a ME. We considered that OSCE is a valuable tool to evaluate PS competencies during clerkship, providing feedback and reinforcing the positive role-models to be followed.

Renata Daud-Gallotti and Iolanda de Fátima Calvo Tibério

Department of Internal Medicine

University of São Paulo School of Medicine

São Paulo, Brazil

E-mail: [email protected]

Medical education reform in Taiwan

Dear Sir

Medical education reform in Taiwan has taken big steps since 2002 not only to meet the needs of society, but also to reassert the basic humanitarian values in medical practices. Medicine in Taiwan has been long regarded as a decent and highly-respected career; however, young Taiwanese physicians are blamed for gradually losing their devotion to the profession due to the increasing complexity of biomedical technology, marketization of medical care, and domination by health care management that often overturns professional decisions for cost concerns. In 2002, Taiwan’s medical schools began to initiate curricular reform which was impelled by the Taiwan Medical Accreditation Council (TMAC) of National Health Research Institute (NHRI). This reform echoed the global concerns ‘of what skills, what attitudes, and what values should medical student achieve before receiving the medical degree’ (Wear 2000).

To monitor this national reform project, we devised questionnaire based on codes of conduct aimed at good doctoring and devised on five constructs as essential to measure professionalism with a six-point Likert’s scale. The data were collected from 563 first- to fourth-year undergraduate medical students at nine medical departments between April and June 2007 in Taiwan. The students scored highest on teamwork (mean = 5.16, SD = 0.66) and interpersonal skills (mean = 5.16, SD = 0.62), followed by medical knowledge and skills (mean = 5.13, SD = 0.57). Students placed less importance on public health duty (mean = 5.03, SD = 0.75) and protection of patients’ rights (mean = 5.06, SD = 0.64). This result is different from previous research which contended that medical students placed primary significance on the construct of medical knowledge and skills and paid less attention to the other constructs (Stern, 2006). Our research showed preliminary success of the current medical education reform, which focused primarily on medical humanities curriculum for pre-med students (that is, first- and second-year students). Nonetheless, students’ awareness of public health duties and patients’ rights protection still need improvement. This seems to indicate that the humanities-centered curriculum have greater transformative effect on the pre-med students than medical students (that is, third- and higher year students), possibly due to the common observation that after the third year, students begin to take systematic pre-clinical and clinical courses and neglect courses outside of clinical education. Therefore, we are currently conducting a longitudinal follow-up survey to further identify the progress of this reform.

Chiung-Hsuan Chiu

Health Care Administration

Taipei Medical University

250 Wusing St

Taipei 110

Taiwan

Duujian Tsai

Graduate Institute of Humanities in Medicine

Taipei Medical University

250 Wusing St

Taipei 110

Taiwan

E-mail: [email protected]

Singing and learning physiology

Dear Sir

Malaysia has a unique, multiracial community comprising there major ethnic races: the Malays, the Chinese and the Indians. This demography is reflected in the medical schools (about 20, including both public and private schools). English is the medium of instruction in all the Malaysian medical schools, although all students read and write Malay, the national language, well.

In my lectures to students in University of Malaya, the first Medical School in Malaysia, I have often incorporated the use of poems and songs to maintain interest in the physiological content of the lecture. Some of these rhymes and songs are written to popular Malay melodies and verse, and without exception the students always enjoy and seem to remember them better than the written lecture details. I have also composed physiological songs in English and one is written to a popular carol sung during Christmas which is also celebrated in multiracial, multi-religious Malaysia (Cheng 2008).

Below is another example of a physiological song constructed to highlight an important aspect of cardiovascular physiology:

‘O My Starling’ (to be sung to the tune ‘O My Darling’)

O My Starling, I Am Fainting

I’ve Been Standing A Long Time

Gravity Pulling, Venous Complying,

SV Falling, I’m Going Supine.

O My Starling, Sympathetic Increasing

Venoconstricting, Give Me Some Time,

Venous Returning, Cardiac Lengthening,

SV Improving, I’m Just Fine.

The major physiology in the song highlighted for the students is what is called the ‘Starling’s mechanism or law of the heart’, after Ernest Starling who detailed and described it. This homeostatic mechanism helps to maintain an adequate stroke volume (SV) when there is fluctuation due to, e.g posture (gravity effects during prolonged standing). Starling’s mechanism operates when the ventricles are filled with a larger volume of blood (cardiac fibre lengthening). An increased end-diastolic volume produces a corresponding stronger ventricular contraction to restore the stroke volume. The compensatory mechanism involved in maintaining SV during standing includes sympathetic activation. Sympathetic venoconstriction decreases the venous compliance (gravity causes venous pooling of blood due to high venous compliance) and improves the venous return and filling of ventricles. Without adequate SV a person will experience postural hypotension and faint.

These enjoyable aids to learning have also been creatively and effectively used by others teaching physiology (Cliff et al. 1997).

Hwee Ming Cheng

Faculty of Medicine

University of Malaya

50603 Kuala Lumpur

Malaysia

E-mail: [email protected]

Certificate course in outcomes research

Dear Sir

Outcomes research that links efficacy and effectiveness is vital for improving the quality of healthcare. Despite the exponential growth in the availability of biomedical data, the conversion of data into clinically useful information is a challenge, in part, due to the lack of outcomes researchers who are adequately trained to query, analyse and extract meaningful information from biomedical databases. Although there is a growing need for more highly skilled outcomes researchers, training programs remain insufficient, in both quantity and quality.

This letter outlines a certificate course in outcome researches recently launched at Duke-NUS GMS, Singapore. The course incorporates innovative training methods with unique hands-on strategy, utilizing traditional and e-learning environments to guide healthcare researchers in efficiently moving from a dataset to a high-quality publication (Ostbye et al. 2004; Pietrobon et al. 2004).

The logistics of the course are divided into pre-class preparation that introduce new concepts and technological tools through readings, educational videos and simulation exercises; in-class sessions that consist of a brief lecture followed by participant presentations and discussions about the application of the theory to research projects and online sessions that enable participants and mentors to interact in a virtual environment. The course consists of 14 modules. Project-based modules teach basic principles of research question formulation, literature search and review, interpretation of statistical findings and manuscript writing, while environment-based modules are used to train data analysts, editors and IRB specialists who help the researchers.

Participants are guided by local instructors who moderate the in-class sessions, clinical mentors who ensure that the project has clinical significance and distance mentors who assist with the project's methodology. The final outcome measure of the course is a manuscript that is ready for journal submission.

Dimple Rajgor & Jatin Shah

Duke-NUS Graduate Medical School, Singapore

Sun Kuie Tay

NUS – Faculty of Medicine, Singapore

Truls Ostbye Eric L Eisenstein Ranga Krishnan & Ricardo Pietrobon

Department of Surgery

Center for Excellence in Surgical Outcomes

Duke University Health System

DUMC 3094

Durham, NC 27710

USA

E-mail: [email protected]

Internal medicine residents’ perceptions of the learning environment in Dutch teaching hospitals

Dear Sir

The Dutch government aims to introduce quality competition in postgraduate medical training. Hospitals’ performances in this area should therefore become more transparent. An important aspect of the quality of medical training is the clinical learning environment. The Postgraduate Health Educational Environment Measure (PHEEM) provides a questionnaire to measure this (Roff et al. 2005). The PHEEM contains 40 items to be scored on a Likert-scale of 0 (very negative) to 4 (very positive). The Dutch version is found to be reliable as a 1-dimensional questionnaire for measuring hospitals’ learning environment (Boor et al. 2007).

In September 2007, the PHEEM was send to all internal medicine residents in the Netherlands (n = 800). The completed anonymous questionnaires were returned in a timely manner by 35% of the residents. In our sample, the questionnaire had a high internal consistency. The average score is 105 (possible maximum score is 160), implying a clinical learning environment that has more positive than negative aspects with room for improvement (Roff et al. 2005). Improvements should focus on the items with the lowest average score; i.e. improving the quality of the accommodation available for residents, improving the catering facilities, and bleeping residents less frequently for inappropriate reasons. For analysing differences among Dutch teaching hospitals, we computed the overall score for each individual hospital. The average PHEEM scores differ substantially. Although for most teaching hospitals the number of residents is rather low, for others the number of respondents is sufficient to provide a reliable evaluation of the learning environment. Hence, because of its reliability and consistency, the PHEEM is potentially useful for stimulating quality competition among Dutch teaching hospitals. For instance, the government could reward hospitals with an above-average performance by allowing them to train more residents and/or by paying them a higher compensation fee.

Annemieke Leunis

Institute of Medical Technology Assessment (iMTA)

Erasmus University Rotterdam

Rotterdam, The Netherlands

E-mail: [email protected]

Marco Varkevisser

Institute of Health Policy and Management (iBMG)

Erasmus University Rotterdam

Rotterdam, The Netherlands

E-mail: [email protected]

A comprehensive communication skills teaching elective for senior medical students: A pilot program

Dear Sir

Over the past decade, the potential role and benefit of the medical student as a teacher has been recognized and some medical schools have begun to incorporate advanced level medical students as effective teachers of communication and physical diagnosis skills courses (Haist et al. 1997; Haist & Wilson 1998). To the best of our knowledge, there has been no formal attempt to include students in the development and revision of course curriculum. We sought to address this gap by offering a comprehensive ‘Communication Skills Teaching Elective’ at the Cleveland Clinical Lerner College of Medicine of Case Western Reserve University (CCLCM).

Our objectives for this elective were for student preceptors to: (1) gain exposure and experience to relationship-centered communication and teaching skills; (2) participate and contribute to program development and curriculum planning; (3) demonstrate effective written and oral assessment of students; and (4) benefit from professional development.

Each student preceptor was paired with a behavioralist or a physician as their co-preceptor. Student preceptors were expected to participate in all aspects of the communication skills course related to teaching, assessment, and curriculum planning. The students were included in faculty development sessions and pre-session faculty debriefings. Their attendance at bi-weekly meetings with the course directors and standardized patient coordinator allowed for consistent involvement in course development and revision. The students met with the course directors at least twice during the year specifically to discuss their progress toward their learning goals.

The course was formally evaluated through course surveys and a focus group was developed by the student preceptors and a medical educator experienced in program evaluation

Eighty-nine percent of the 19 students who completed the formal survey agreed that they would recommend a student preceptor. Common benefits cited by students in the focus group were: insight into the utility of communication skills, provision of high-quality feedback used as portfolio evidence, and sharing of personal clinical experiences and strategies. Faculty appreciated the student preceptors’ ability to validate the utility of course content. Course directors indicated that student preceptors made substantial suggestions for refining the curriculum including case revision and methods for tracking student progress. The student preceptors reported improved confidence in effectively employing relationship-centered communication skills, gaining teaching experience, and obtaining a unique perspective on medical education development and evaluation. Our pilot suggests benefit from including students in a comprehensive teaching elective that includes curriculum development and planning in addition to direct teaching time.

Dawn M. Wiese, J. H. Isaacson, Amy Windover, Lily Pien, Benjamin Larson

Cleveland Clinic Lerner College of Medicine

9500 Euclid Avenue

Cleveland

OH 44095, USA

E-mail: [email protected]

The 1st Annual Review of Competence Progression, a new way of assessing trainee doctors: Trainees’ perception

Dear Sir

Postgraduate medical education and assessment have undergone numerous changes in the recent past in the UK with the emphasis moving from gaining knowledge and skills to competency acquisition (Delamothe 2008). As part of these changes, the Annual Review of Competence Progression (ARCP) has been designed as a formal process to facilitate assessment of trainees’ competency in various domains. The first ARCP was completed nationally in England in 2008. This study examined the trainees’ experience of the process from a cohort of specialty trainees’ year 1–4 (ST 1–4) in psychiatry from the North of England.

A cross-sectional survey was conducted. An electronic questionnaire was developed and sent by e-mail to all trainees within a few days of undergoing the ARCP. The question items were categorical (yes/no) or Likert-type. Free text was allowed for comments to some of the questions.

From 92 psychiatry trainees who underwent the ARCP in the Northern Deanery, 58 (63%) completed the survey. Of the trainees 79% perceived a varying range of difficulties during the ARCP process. These included inadequate information on the required content and structure of the portfolio (48%); non-availability of a standardised list of acceptable evidence (75%); difficulties in completing work place-based assessments due to non-availability of assessors (42%) or inadequate training of assessors (36%). There were technical problems with the designated website for online assessments (72%) and lack of robust feedback at the ARCP.

To conclude, the trainees have experienced some difficulties in the first ARCP. Since the survey was conducted, The Royal College of Psychiatrists has replaced the previous online assessment system (reference 2), which would hopefully reduce the technical problems. The feedback from this survey has also been provided to local and national educational meetings and it is hoped that this may help in making further improvements.

A. Vasudev

Wolfson Research Centre, Institute for Ageing and Health

Campus for Ageing and Vitality,

Newcastle upon Tyne, NE4 6BE, UK

E-mail: [email protected]

P. Thakkar

Hutton Centre, St Lukes Hospital

Middlesbrough, UK

E-mail: [email protected]

K. Vasudev

Specialist Registrar, Rehab Psychiatry, St Georges Park

Morpeth, Northumberland

E-mail: [email protected]