Letter to the editor

The role of radiology in the undergraduate medical curriculum

Dear Sir

A letter by Zafar titled “Radiology: An underutilized resource for undergraduate curricula” caught our interest as we have a novel way of introducing radiology into our undergraduate curriculum.

During our pediatric clerkship rotation, students are required to generate 10-minute case presentations using a template PowerPoint outline. The guidelines are: “keep the presentations visual and simple and stick to the template”. The cases are presented at the end of the Pediatric clerkship both at the tertiary care center and our regional district sites via Bridget® conferencing software (Blake et al. 2008). The best presentations have been edited by faculty and uploaded to the Dalhousie medical school intranet for all students to access. This provides a wonderful resource for all learners.

Of relevance is that over 50% of the presentations have radiological content. Students are prompted by questions to indentify bronchiolitis on a chest radiograph, recognize fracture patterns in child abuse, and order a CT study for suspected orbital cellulitis.

This learning approach highlights a number of salient points regarding radiology and its role in the medical curriculum.

Firstly, undergraduate radiology teaching is often spearheaded by nonradiologists who recognize imaging as an invaluable teaching tool and view basic radiology skills as essential to future clinical practice.

Secondly, using imaging to visually demonstrate anatomy and pathophysiology with clinical cases helps to form a fundamental bridge from the preclinical curriculum to the clinical clerkship years. We see these cases being relevant to all years of training.

Beyond this, the student-generated case-presentation model demonstrates radiology concepts, which are both clinically relevant to the learner and appropriate to their level of training and experience. Moreover, this model can easily be incorporated into any clerkship rotation and seamlessly built into the existing (and already “packed”) medical program requiring no extra time, and few additional resources.

In summary, the student generated case presentations are a simple, cost and time efficient, practical method to incorporate core radiological content within a clinical context. This meets Dr Gunderman's criteria for an integral role for radiology in the education of medical students (Gunderman et al. 2003). As diagnostic imaging becomes common place radiologists and clinicians need to work together to establish a core set of undergraduate radiology objectives to prepare students for their future career as physicians.

Kim Blake

IWK Health Centre

Department of Pediatrics

5850/5980 University Ave

Christina Paquette

IWK Health Centre

Radiology Resident

Halifax

Nova Scotia B3K 6R8

Canada

E-mail: [email protected]

Metacognitive awareness and academic achievement in medical students

Dear Sir

Metacognitive awareness is an essential component of self-regulated lifelong learning and a recently published study identified a significant positive difference between metacognitive awareness, as measured by the Metacognitive Awareness Inventory (MAI), of medical students on a problem – based curriculum compared with students on a traditional curriculum. (Turan et al. 2009). An important question that remains unanswered is whether increased metacognitive awareness is associated with an impact on the academic performance of medical students. We found no previous relevant studies that attempted to answer this question.

We used the same MAI questionnaire that was used in the reported study to survey all our final year undergraduate medical students on a non-problem based learning curriculum. The response rate was 71 percent, with 178 fully completed questionnaires returned. We found no statistically significant relationship between the MAI scores (total and subgroup) and the total scores for the Objective Structured Clinical Examination (OSCE), Written Paper (EMQ - Extended Matching Questions) and the combined OSCE and Written Paper from both their final year and third year examinations (Pearson correlations, p > 0.05).

We recommended that further research into metacognitive awareness and academic performance in medical students uses methods that are not based on self-report but can identify metacognitive awareness and self-regulatory learning processes during authentic learning activity, such as talk aloud protocols or micro-analytic approaches (Zimmerman 2008). These these methods are essential if medical educators are to fully understand the impact of different curricula.

John Sandars

Senior Lecturer

Medical Education Unit

The University of Leeds

Leeds LS2 9LN, UK

Tel: [phone]

Fax: [phone]

E-mail: [email protected]

Matt Homer

Research Fellow and Statistical Consultant

Medical Education Unit

The University of Leeds

Leeds LS2 9JT, UK

Ethics

The research protocol was approved by the Medical Educational Research Ethics Committee of the Leeds Institute of Medical Education at the University of Leeds.

Conflict of interest

None.

Cultural characteristics and educational differences in medical students

Dear Sir

Globalization has profoundly affected all health care by increasing the diversity of clinicians and their patients. Worldwide, medical schools highlight the need for students to understand and show respect for their patients, classmates, teachers and peers of different ethnicities. Student migration will remain one key domain for the emergence of global labor market. Enhanced cooperation for Europeans and Chinese on information sharing, data exchange and orderly management of return migrants, can boost the potential benefits for both parties in a long run (Phillips 2008). However, student well being should not be neglected. The health of the student is as important as an excellent education. It may even be the case that excess stress may impair learning.

In the past, traditional Chinese medical students studied passively, learning without comprehension and received mechanical training. The personality types of Chinese medical students may be somewhat different from the personality profiles exhibited by medical students from other nations (Zhang et al. 2004). These characteristics may be of value to individuals who desire to investigate personality type differences among medical students with different cultural backgrounds. The association of cognitive processes, family condition, societal values, mental status and learning behaviors are dynamically intertwined with time and environment. However, longitudinal and multi-dimensional research in this area is very limited (Fischer et al. 2008). It is important for contemporary medical education to develop a framework for the theory and practice and development of all medical students that leads to their attainment of professional, sociological, and psychological competencies. Particular social economic status factors may increase the risk that medical students will experience stress, mental disturbances, and status attainment. Chinese parents care very much about their children's occupation and focus on related factors of occupational reputation, professional skills, respect, social contribution, knowledge, and income. For Chinese people, the occupational reputation of doctors is still relatively high in the occupational reputation hierarchy. Therefore the pressure on Chinese medical school students is increased rather than decreased, even though they are adults.

Depressive mood, family environment, self-concept, sleep and even food were important factors affecting the well being of medical college students of ethnic minorities. The quality of life in these medical students needs to be improved. The Institutes need to take such issues seriously in order to help medical students complete their studies.

Ming-Chen Hsieh

Division of General Internal Medicine

Buddhist Tzu Chi General Hospital

School of Medicine, Tzu Chi University

Hualien, Taiwan

E-mail: [email protected]

Case-based introduction to medical statistics for health professionals by peers

Dear Sir

With the fast development of computing facilities in recent years, statistical analyses have become considerably more complex than a few decades ago. However, the graduate and postgraduate medical training has hardly followed these trends and several studies have indicated that the statistical literacy of physicians and other health professionals is far below the desired level (Windish et al. 2007).

Learning to perform simple univariate analyses, which is the main teaching objective for a typical short introductory course in biostatistics, is not enough today for health professionals in order to be able to interpret and critically evaluate the medical literature or to communicate fruitfully with statisticians when performing one's own research.

We have developed a one-week postgraduate course to fill this gap at Karolinska Institutet. The course is based on five research papers with increasing complexity in terms of the applied statistical methods. The papers are distributed before the course starts, together with study questions, to help the teachers adjust the course and prepare the participants. During the course and for the examination, a number of research abstracts which include statistics are also read and interpreted. The course does not aim to teach how to perform statistical analyses. Instead, it provides an overview and guiding for interpretation of the results, including the typical pitfalls and misconceptions. It covers the most frequently used methods today, including those usually considered to be advanced, like survival analyses, mixed models and the concept of interaction.

A unique feature of the course is that the teachers are statistically trained medical doctors. Due to their medical background, the teachers can use the language of their medical professional peers and can avoid formal mathematics unless it is absolutely necessary and can easily back up their explanations with real life examples whenever needed. Teachers that are closer to the academic background of the students may also understand better their difficulties and this may also lead to a more relaxed and open relationship. Our course is highly appreciated by our students who consistently report their strong support for the idea of learning statistics from peers at an introductory level.

Imre Janszky*, MD, PhD

Jette Möller, PhD

Terese Stenfors-Hayes, MA

Rickard Ljung, MD, PhD

Karolinska Institutet, Stockholm, Sweden

*E-mail: [email protected]

Integrating Evidence Based Medicine into the medical curriculum: barriers, enablers and implementation strategies

Dear Sir

Evidence Based Medicine (EBM) is an essential way of teaching and practicing medicine in an uncertain environment. EBM is faced with the challenge of integration, not only to one discipline of clinicians, but a whole health care team who may utilise these principles during their daily clinical practice. The key step to adopting such an approach is teaching the benefits, and limitations, of EBM to new healthcare undergraduates and embedding it within their culture as students, and as future clinicians.

Different medical disciplines may have different interpretations of how EBM is defined and integrated within clinical practice. A recent study exploring surgeon's attitudes to EBM in practice identified that whilst EBM generated knowledge is useful and often used in practice, absence of evidence does not hinder their ability to make a clinical decision. (Kitto et al. 2007)

We conducted focus groups with 23 third-year undergraduate medical students with the aim to identify enablers and barriers to teaching EBM. Focus groups were guided by semi-structured interviews, with the discussions transcribed verbatim and the data analysed independently by the two authors via thematic analysis. (Rice & Ezzy 1999)

Key facilitators for promoting EBM to medical students and future clinicians include competency in EBM, mentorships and a demonstrable applicability to clinical disciplines. Barriers to its implementation include a disassociation with senior clinicians, and constraints experienced by a lack of resources. An appropriate method for implementing the widespread use of EBM may reside in Journal clubs.

Many hospitals and departments routinely run journal clubs. Journal clubs have the potential to bring together medical students, early, mid and senior clinicians in the single forum to appraise and discuss the application of evidence to specific patient cases evident in the hospital. This provides an environment in which the medical student can observe the role of evidence in decision making between clinicians. It also provides an environment in which senior clinicians may gain skills and knowledge to increase their competency in EBM.

Further research is required to gain a better understanding of the cultural and organisational barriers to the implementation of EBM in teaching and practice. Only once such barriers are identified can there be informed development of strategies to better integrate EBM principles into existing medical curricula as well as translating it to daily practice within the clinical environment.

Dragan Ilic* and Kristian Forbes

School of Public Health & Preventive Medicine

Monash University

Clayton VIC 3168, Australia

*E-mail: [email protected]