Small group radiology exposure during gross anatomy

Dear Sir

The traditional approach to anatomy instruction during the first year of medical school has seen numerous changes over the past 20 years. Incorporation of radiologic imaging provides students with an introduction to clinical medicine as well as supplements anatomical knowledge. Diagnostic imaging has been shown to be a beneficial adjunct to dissection (Ganske et al. 2006).

Our department's participation in the gross anatomy course includes both large group lectures as well as small group sessions during which each anatomy table group reviewed postmortem computed tomography (CT) images of their cadaver with a preceptor. A web-based survey of the medical students was conducted following the completion of the course to evaluate their opinion of the radiology component of the course. The project was given exemption status by the Institutional Review Board.

The survey consisted of 12 statements, based on a Likert scale from 1 to 5 (1 = strongly disagree and 5 = strongly agree). The two statements that are the focus of this letter are: ‘Small group sessions in radiology were helpful to my learning’ and ‘Large group sessions in radiology were helpful to my learning’.

Students felt that the small group sessions were helpful in their learning (mean 3.66, SD 0.80) and felt that they were slightly more helpful than the large group sessions (mean 3.10, SD 0.98), not statistically significant. Each class independently rated the small group sessions more helpful. Sixty-five percent of respondents either agreed or strongly agreed that the small group sessions were helpful, while only 38% of respondents either agreed or strongly agreed that the large group sessions were helpful.

The use of portmortem CT scanning not only appears to yield greater understanding of anatomy, but it allows the student to begin to think as a clinician, relying on modern imaging technology to enhance what is seen during examination (or dissection). The use of small groups was found to be especially helpful and may lay the groundwork for future collaboration as part of a clinical team.

Allison Grayev* & Kaitlyn Weidenbach

Department of Radiology

Creighton University School of Medicine

601 North 20th Street

Omaha, NE 68131, USA

*E-mail: [email protected]

Bioethics statements agreement levels among medical students–Comparison between problem-based and traditional medical curricula

Dear Sir

There are conflicting reports regarding the impact of teaching ethics on the behavior of medical students (Goldie et al. 2002). We compared the level of agreement with ethics statements amongst medical students taught by traditional methods (TD) with students taught by problem-based learning (PBL) methods.

Students were asked to grade their degree of agreement in 19 ethical statements (using a Likert-type scale of 1–5) covering five domains: goals of medicine, autonomy, quality of life, resource allocation, and treatment withdrawal. There were 43 PBL students and 83 TD students.

We found significant differences between the overall mean scores by PBL (4.03 (0.69) and TD students (3.75 (0.68) (p = 0.001). The main differences between the two group of students were seen in the domains of autonomy (p = 0.0001), patient centeredness (p = 0.02), and informed consent (p = 0.05). We also observed a higher paternalistic attitude in TD students compared to PBL students, these differences were observed early in their courses.

We speculate that these differences are related to the different bioethics teaching and training methods used in the two groups. We argue that ethical teaching methods utilizing PBL might be more effective in teaching ethics. In this connection it should be noted that the ethics courses given to our TD students were limited largely to didactic teaching consisting of few hours annually.

Another possibly relevant difference in the teaching methods in the two groups might be the use of simulators for the PBL students and not for the TD student. A recent study (Amitai et al. 2006) has concluded that using simulators sends a clear message to students that patients are not to be used as commodities for training. This, it is felt, enhances ethical sensitivity among students particularly in the area of autonomy and informed consent.

Abdulla Al Sayyari*, Thamer Yateem & Tareef Ashour

College of Medicine

King Saud Bin Abdulaziz University for Health Sciences

Riyadh, Saudi Arabia

*E-mail: [email protected]

The development of a cultural competency observational tool

Dear Sir

Increasingly, physicians are caring for people of varying cultural and linguistic backgrounds. Due to a reported lack of observational tools for the evaluation of cultural competency in the health care setting (Resources for Cross Cultural Health Care, US Department of Health and Human Services office of Minority Health & Agency for Healthcare Research and Quality 2001), we developed a behavioral checklist based on the observation by an inter-professional inter-cultural panel.

Discriminatory care was extremely difficult to discern through observation alone. Nonetheless, dismissiveness emerged as an observational red flag for the possible influence of discrimination. The combination of knees and eyes both pointed away from the patient for prolonged periods was an observed marker for disengagement or dismissiveness. Dismissiveness had various forms, including failure to address a patient's explanatory model, ignoring new questions, or glossing over follow-up questions as unimportant. We found these barriers most often in the setting of the culturally-laden issues of disability, mental illness, and pain.

In the most egregious cases, physicians were focused on a variety of administrative and paperwork tasks rather than medical care, or were providing care that was not evidence based. In settings where physicians are caring for distressed groups, social-economic-cultural differences exist between patients and care-givers which when misunderstood can adversely affect patient–doctor interactions. These misunderstandings may reflect difference in culturally or personality determined values with effects ranging from mild discomfort to non-cooperation to major lack of trust that disintegrates the therapeutic relationship.

Our observational rubric includes rating of the elements defined in Makoul (2001) regarding patient centered communication. These elements are augmented with sections that highlight factors that emerged in our observations relevant to intercultural communication such as language and interpreters, non-verbal communication, issues with a large cultural overlay (mental health, pain, and disability). The CCOT is a 10-item tool with a Likert scale, available from the authors, anchoring behavioral descriptions into a continuum including, ‘incompetent’, ‘task-centered’, ‘physician-centered’, and ‘patient centered.’

Future studies will be required to validate our instrument in terms of inter-observer reliability and to tie it to patient outcomes.

David Richard Brown*

Herbert Wertheim College of Medicine

Humanities, Health & Society

Florida International University

11200 SW 8th St, HLS II 693

Miami

FL 33199, USA

*E-mail: [email protected]

Michael J. Celestin

Department of Family and Community Medicine

University of Miami Miller School of Medicine

Agueda Hernández & Luther G. Brewster

Department of Humanities, Health & Society

Herbert, Wertheim College of Medicine

Florida International University

11200 SW 8th St, HLS II 693

Miami

FL 33199, USA

*E-mail: [email protected]

Timothy E. Spruill

Department of Family Medicine

Florida Hospital,

Orlando

FL, USA

Barry Nierenberg

Center for Psychological Studies

Nova Southeastern University

Miami

FL, USA

Cheryl D. Brewster

Department of Family Medicine & Community Health

University of Miami Miller School of Medicine,

Miami

FL, USA

Siri Akal

Red Hood Family Practice

John Bryan Page

Department of Anthropology

University of Miami,

Coral Gables

FL, USA

Acknowledgment

This research was supported by a Title VII Primary Care Training Grant from the Health Resources and Services Administration (HRSA).

Unavailable novel questionnaires in published medical education research

Dear Sir

Medical education research frequently uses questionnaire methodology, and readers of published medical education research should ideally have access to the questionnaires used in the study so that they can evaluate the validity and reliability of the findings. This is particularly important when the questionnaire is novel or adapted.

Our experience suggested that many such questionnaires were not available to the reader. We conducted the following survey to see if novel or adapted questionnaires in the medical educational literature were available to readers.

We examined three medical education journals in 2008: Medical Education, Medical Teacher and Academic Medicine. We found 243 articles that reported original research. Of these, 148 articles contained a questionnaire. Of these, 117 articles contained a questionnaire that was either novel or adapted. Amongst these, 24 articles provided the complete questionnaire or a link to the complete questionnaire in print or online. This left 93 articles that reported original research that contained a novel or adapted questionnaire where the complete questionnaire was not provided (in print or online). We emailed the corresponding authors of these articles to ask them to send us the full questionnaire. One replied that they did not wish to take part. Three email addresses did not work. Within 1 month, 31 authors replied sending us the questionnaire or a link to the questionnaire. This left 58 articles where the novel or adapted questionnaire was not accessible.

Large numbers of questionnaires in published medical education research are not available. This lack of access limits the evaluation of such research. It also means that some researchers could inadvertently and unnecessarily replicate studies because they did not know what has been done previously.

Some researchers may be unwilling to share their questionnaires out of fear that others will use them without an acknowledgement. However we feel that fear of inadvertent usage is not an adequate reason in itself to make questionnaires unavailable.

Until recently, the limited space available in print journals affected the ability of such journals to publish questionnaires completely. However with the advent of the internet, a link can be provided. In view of our findings we call for all questionnaires used in medical education research articles to be made completely available.

Kieran Walsh*, John Sandars & Fiza Ahmed

BMJ Learning

BMJ GroupTavistock Square

London WC1H 9JR, UK

*E-mail: [email protected]

Long-lasting musculoskeletal complaints and computer use among medical students

Dear Sir

Musculoskeletal complaints are an important health problem in developed countries. Western university students are widely reporting to have a high prevalence of computer-related musculoskeletal problems. We hypothesized that medical students would also experience a high prevalence of musculoskeletal complaints generally, due to the high attendance of courses and additional home study required. Knowing that education by computer has become more and more important in medical faculties, sitting for long periods of time in the same position increases the probability of musculoskeletal complaints, especially in the upper extremities and/or neck can be expected. As medical students form the basis of our future health care, we need to ensure that early departure from the health care system is not due to the result of musculoskeletal complaints.

In our 2008 survey comprising of 131 out of 133 selected Dutch medical students (third-year undergraduates), reports were sampled on musculoskeletal complaints, associated restrictions, and hours of computer use. More than three quarters of the students reported having long-lasting musculoskeletal complaints in at least one area of the body during the 6-month period. Additionally, upto one-third of those students reported functional restrictions associated with their complaints. The average computer time per week was 16 hours. More musculoskeletal complaints were reported with the increase in computer use, complaints occurring from 1.4 to 3.2 times more often.

Important findings regarding the consequences of the increase in computer use among students, the future role of the medical student and the predicted negative impact this will have on specifically the health care system and society in general are as follows: First, students suffering with musculoskeletal issues at an early age could highlight the start of a lifelong problem. Second, while computer use is increasing in the education of medical students, we have to be cautious as a rise in musculoskeletal complaints is expected. An important next step will be the introduction of preventive programmes, providing students with extensive information on the risks of prolonged computer use and ways in which to reduce the chances of musculoskeletal complaints. From the medical school point of view, computer-based education should be given with care and attention to possible risks. The efficacy of preventive programmes should be evaluated and reviewed carefully.

Rianne M. Blom, Sinan M. K. Belhawi

Monique H. W. Frings-Dresen & Judith K. Sluiter*

Coronel Institute of Occupational Health

Academic Medical Center

University of Amsterdam

PO Box 22700

1100 DE Amsterdam

The Netherlands

*E-mail: [email protected]

Inculcating practices based on adult learning principles in medical schools-a possible framework for professional development?

Dear Sir

Faculty development in India is in a germinating stage (Adkoli & Rita 2009). Medical teachers are challenged to balance their teaching, patient care and activities related to professional development. Melaka Manipal Medical College (MMMC), Manipal University, India has adopted certain practices based on adult learning principles in order to foster professional development of faculty members. We tried to record the perceptions of academic faculty at MMMC regarding the avenues available for professional development through these practices.

Initially, a focus group discussion was conducted among selected faculty members to understand their perceptions on adult learning. Based on the focus group discussion and literature review performed, a questionnaire comprising 23 items focusing on five adult learning principles (active participation, relevant learning, constructive feedback, safe, non-threatening environment and previous experiences) was designed. Faculty members (n = 23) were asked to respond on a 5 point Likert scale. Additionally, a force field analysis was carried out where in faculty were asked to identify three factors which facilitated their conscious involvement in activities related to their professional development and three factors that hindered their professional development.

Among the five characteristics, relevant learning was found to have the highest mean value (4.37), followed by active participation (3.72), previous experiences (3.65), constructive feedback (3.59) and a safe non-threatening environment (3.50). Frequency analysis of responses indicated that at MMMC, there was ample scope (91.3%) for relevant self-learning that fostered professional development. Force field analysis revealed that our medical school offered considerable flexibility and opportunities for continuing professional development along with faculty members’ prevailing role as teachers. Nevertheless, the need for more research facilities and funds were highlighted.

An organized attempt to create awareness among the medical school faculty about the scope of adult learning practices would help in nurturing professional development, especially in resource poor settings.

Reem Rachel Abraham, Vinod Pallath

Ciraj AM & K.Ramnarayan

Melaka Manipal Medical College (Manipal Campus), India

Asha Kamath

Selection Grade Lecturer in Biostatistics

Kasturba Medical College

Manipal, India

E-mail: [email protected]