Letters to the Editor

Impact of High School Certificate scores on the selection process of medical students

Dear Sir

The medical school selection process is a complex phenomenon and yet a matter of continuous debate. Medical schools need selection procedures that are evidence based and legally defensible (McManus et al. 2005). Current selection methods in medical schools emphasize the academic competence, somewhat to the detriment of other essential competencies. A selection method can only be justifiable for usage if it proves to be reliable across several cohorts of candidates and if it predicts the performance later on.

Most of the studies which have explored the relationship between the admission criteria and the subsequent performance were conducted in western countries. The numbers of studies dealing with the predictive value of high school results for the study progress in medical school in non-western countries are very limited. Despite High School Certificate (HSC) score being the basis for selection in the Kingdom of Saudi Arabia, little evaluation of its predictive validity has taken place. In a retrospective longitudinal study in our college, results of 539 students from seven cohorts (admitted and graduated between 1998 and 2009) were analyzed using Pearson correlation and regression analysis. HSC scores of all cohorts were positively correlated to the academic performance in medical school, expressed as Grade Point Average (GPA), but the relationship is moderate (0.476). These findings are consistent with other research reports wherein positive correlations have been observed between the HSC scores and the medical school grades (Ferguson et al. 2002). The results of our study, however, do not reveal a prominent predictive validity of HSC scores. In fact, the regression model can only explain just one-fourth variation of GPA which is a poor predictive value of this selection tool. So, definitely, students’ characteristics other than school results play an important role in the academic performance. Indeed, characteristics such as motivation, commitment, personality and attitude have strong influence on performance at medical schools (McManus et al. 2005).

This study shows that HSC scores are only weak predictors of academic performance during medical school. Consequently, admission predominantly based on previous academic performance can be biased and presumptuous which could allow unsuitable candidates to become future doctors. Therefore, it is time to review selection criteria for medical schools. A mixture of selection methods covering a broad range of attributes is likely to provide the best way of selecting future doctors.

Syed Imran Mehmood. Medical Education Development Centre, College of Medicine, King Khalid University, Abha, Saudi Arabia. E-mail: [email protected]

Jan C.C. Borleffs. University Medical Center Groningen, Groningen, The Netherlands, University of Groningen, Groningen, The Netherlands.

Students’ perspectives regarding an ideal PBL case

Dear Sir

Melaka Manipal Medical College (MMMC), Manipal Campus, India, follows a hybrid curriculum where 30% of the curriculum is covered through problem-based learning (PBL). MMMC conducts PBL modelled on the Maastricht ‘seven jump’ approach. At MMMC, PBL coordinators monitor and periodically review the PBL process by recording faculty and students’ feedback and later present and discuss in ‘PBL shot’ during weekly faculty council meeting. The topic allotted for one of the ‘PBL shot’ presentations was ‘designing effective PBL cases’.

MMMC faculty design the PBL cases based on the ‘seven principles of effective case design in PBL’ as proposed by Dolmans et al. (1997). To make PBL cases more effective, we decided to investigate students’ perspective regarding qualities of an ideal PBL case.

Initially, students (14 groups (n = 10) were asked to identify the properties of an ideal PBL case. After 5min, a case designed by MMMC faculty was given and students were requested to identify the good and bad qualities of the case. The students already had an exposure to this case during one of their PBL sessions. Later, students were asked to identify the qualities that should be incorporated in the given case to make it an ideal case. Finally, each group was asked to share their opinions with other groups.

Majority of the groups felt that case should be like a story with suspense and minor twists. Students also opined that case should be made more interesting by incorporating patients’ dialogues and by ending the scenario with questions. Students also felt that the case will be interesting if it is related to their age group and based on a present health scenario with an interesting title. Other suggestions were to include video clips, colored relevant photographs and laboratory investigation reports. The study threw light upon the attributes of an ideal PBL case from the student's view point.

Vasudha Devi, Reem Rachel Abraham, Vinod Pallath & Ciraj Ali Mohammed. Department of Pharmacology, Melaka Manipal Medical College, Manipal University, Manipal 576102, Karnataka, India. E-mail: [email protected].

Perceptions of appropriate appearance in the OSCE: A mixed study analysing viewpoints of students and examiners

Dear Sir

‘Evidence based dressing’ (Nair et al. 2002) represents the acknowledgement by the medical profession of the importance of appearance in the medical environment. The OSCE, an assessment tool, is widely used to simulate this environment, e.g. consultations.

We aimed to determine if student and examiner groups had similar views on appropriate appearance in the OSCE. We developed and piloted online questionnaires informed by literature review for each group. Participants were asked to grade their degree of agreement to statements using a likert scale (strongly agree, tend to agree, neither agree or disagree, tend to disagree and strongly disagree). Statements centred on topics identified at review and included: formal versus casual clothing, religious attire, piercings/jewellery, tattoos and, for students only, infection control. Open questions followed each topic to allow participants to explain their choices.

Analysis of open questions utilised content analysis with the quantitative analysis of closed questions. Chi-squared (p-value = 0.01) was used to determine the level of agreement between both groups. A total of 223 students and 34 examiners took part in this study.

The results were interesting. Despite anecdotal evidence, this study showed that views on appropriate presentation during the OSCE are exceptionally synonymous between students and examiners. Both groups preferred formal clothing to casual with one examiner citing professionalism issues with casual attire. Piercings garnered a more interesting response; only ‘stud’ piercing was deemed appropriate by either population. Location was also important with ear piercing widely accepted (p = 0.041); nose piercing gave a mixed response (p = 0.109). Multiple piercings were deemed inappropriate by both populations.

Visible tattoos were unacceptable to both populations (p = 0.690) though responses to open questions suggested that more discreet tattoos, e.g. ‘star on wrist’ may be acceptable. The offensive potential of any tattoo was also important. Both populations were in favour of religious expression, providing it did not affect the doctor/student–patient relationship.

General analysis showed that greater restrictions are imposed on female attire (e.g. length of skirt, make-up, cleavage issues, etc.), which potentially means that females are more prone to inappropriate appearance.

Students’ views on infection control measures (i.e. removal of ties and watches) suggested a lack of support for new measures. Other methods of infection control were proposed, including stethoscope hygiene, better ward cleanliness and the education of visitors. These measures have ‘less of an effect on professionalism (ties) and/or practicality (watches)’. Several students suggested that the doctors should be issued with a separate uniform at work which can be regularly laundered.

Zaid Hussain Khan. 4th Year Medical Student, Hull-York Medical School, England. E-mail: [email protected]

Intercalated project supervised by Connie Wiskin, University of Birmingham, UK.

Medical students' perceptions of homelessness following clinical exposure to homeless patients: A qualitative study

Dear Sir

One role of medical education is to challenge attitudes that may increase inequalities in healthcare, particularly for socially vulnerable populations. One such population is the homeless. Homelessness is a major issue in today's global society, and the homeless often have greater healthcare needs than the general population.

However there are a number of barriers that prevent their access to healthcare; the attitudes of healthcare professionals have been identified as one such barrier. Furthermore, evidence suggests that attitudes are often developed during the education of healthcare professionals (Masson & Lester 2003). Therefore educational interventions represent a key opportunity to challenge these attitudes. Currently, there is limited evidence assessing whether such interventions influence students’ perceptions towards homeless patients.

We conducted a qualitative study to assess medical students’ perceptions of homelessness following a particular educational intervention; in this case, clinical exposure to homeless patients.

A purposive sample was drawn from fifth-year Oxford University medical students who attended Luther Street Medical Centre as part of their GP placement. Nine individuals consented to be contacted, of which six students were interviewed. Recorded 20-minute semi-structured interviews were conducted following attendance at the centre.

A progression in perceptions was observed. Participants no longer viewed homeless patients with preconceived negative stereotypes. Instead, homeless patients were perceived to be less threatening and more deserving of medical and social support. Additionally, participants developed a greater awareness of homeless healthcare issues and expressed an increase in confidence when interacting with homeless patients, and increased willingness to engage with homeless patients in the future.

In this study clinical exposure to homeless patients positively influenced medical students’ perceptions of homelessness. Such a progression in perceptions has the potential to help break down barriers that prevent homeless patients accessing healthcare. The key implication of this study is that clinical exposure to homeless patients may be a valuable addition to medical curricula in the UK and abroad.

Prashant Kumar, Alice Edwards & Peter Bourdillon-Schicker. Medical Students, University of Bristol, Bristol, UK. E-mail: [email protected]

The challenge of introducing a hand hygiene standard to clinical examinations

Dear Sir

International health organizations increasingly emphasize the importance of hand hygiene in patient safety yet as educators we have been slow to adopt this in undergraduate teaching and even slower to apply it as an examination standard. The undergraduate clinical examination observed by physician examiners is designed to test clinical competency. At the National University Hospital in Singapore, we introduced into our examiner standardisation workshops and our marking template a provision whereby marks were to be deducted for failed hand hygiene, as we believed patient safety behavior should not be dissociated from or confused with clinical competence. (Feather et al. 2000) In assessing examiner behavior during the 2010 final MBBS examinations, we found a great reluctance to penalize students for the safety breaches. Over the course of the examination day, 128 examiners observed 218 students in two pediatric and three adult medicine short cases across three hospitals in Singapore.

In a post examination survey, 24% adult and 37% pediatric examiners stated that they would not remove marks for hand hygiene non-compliance. In free text feedback, some examiners believed that students were already under “too much stress” believing it either should not be tested or it could be considered elsewhere, for instance Continual Assessment (CA) or Objective Structured Clinical Examinations (OSCEs). Others felt that it would be reasonable to simply remind candidates so that they would not be penalized. However, the overwhelming number stated that hand hygiene compliance was not reflective of clinical competency (Van Der Vleuten 2000).

Discordance between examiners who were always in groups of two or three was high. In the adult examiner cohort marks were deducted in 64 of the 1308 opportunities, however on 26 (40%) of these, a partner examiner did not. Similarly, in the pediatric examination, marks were deducted in 43 of the 872 opportunities. On 32 (74%) occasions a partner examiner was discordant.

Adherence to standardization guidelines was poor during our recent MBBS short case clinical examination. It is important that this be recognized and that the reasons behind the behavior are identified. Our faculty's failure to distinguish and clarify our desire to test both safety behavior and clinical competence led to confusion, deviation from standardized marking and inconsistency in assessment. It is also possible that examiners themselves do not believe that hand hygiene should be an expectation.

The number of university and specialist credentialing bodies that impose penalties for hand hygiene non-compliance in clinical examinations is increasing. Hand hygiene should be second nature (such as good manners) rather than something to be remembered so “examination stress” should not be a justification.

Medical training institutions must continue to develop innovative means of teaching and evaluating patient safety behavior in tomorrow's health workers.

D. Fisher, M. Aw, L.Y. Hsu, K. Patlovich & K.Y. Ho. National University Health System, Singapore 119074, Singapore. E-mail: [email protected]

Virtual reality simulation: The future of medical training

Dear Sir

We read with great interest the article by Ellaway (2010) regarding Virtual Reality (VR) training and would like to address the key advantages of VR simulation training.

Training opportunities are now increasingly infrequent or even inaccessible to juniors due to patient safety considerations, financial pressures and the reduction in working hours. Therefore, a shift in teaching style from the traditional methods of ‘see one, do one’ to a safer, more efficient and structured regime is urgently required.

Novel high-fidelity VR simulators are a promising training tool for various reasons. Practice on VR simulators enables trainees to acquire technical skills in a safe and structured manner, so that they are more competent and better prepared when encountering real patients. More experienced trainees may also benefit from high-fidelity simulation as difficult anatomy, encountered infrequently in real life, can be easily simulated in VR.

The ability to track training is a key advantage of VR simulation. Inbuilt metrics may be used formatively to provide immediate detailed feedback to trainees or be recorded for standardised summative assessments. Current assessment of technical proficiency is mainly subjective, and often unstructured, unreliable and lacks validity. It can be difficult to standardise assessments in patient-based procedures.

Recently, Aggarwal et al. (2007) demonstrated that a proficiency-based VR training curriculum results in a significant improvement in skills of laparoscopic cholecystectomies. This type of scientifically validated VR training curricula can deliver individualised competency-based training in a safe and effective manner.

However, VR training is often considered to neglect training in non-technical skills such as patient interaction. VR training is not intended to replace traditional bedside teaching, but to be used as an adjunct teaching aid. It is also possible to combine VR technical skills training with a simulated patient, so that procedural skills and communications skills can be practiced together.

VR simulation is a powerful learning tool, to enhance the competency of healthcare professionals in a safe, efficient and educationally orientated manner, and it is likely to become an integral part of future medical training.

A. Banerjee & A.S. Bancil. Imperial College London, London SW7 2AZ, UK. E-mail: [email protected]