Letters to the Editor

Young Chinese medical students adapt well to problem-based learning

Dear Sir

Problem-based learning (PBL) has been introduced by McMaster University, since 1970s. This learning approach requires students to be self-directed and cooperative learners. Although it has been widely accepted around the world, there are concerns that the young age of Asian students and their cultural background may affect their ability to adapt to PBL.

Since 1997, Li Ka Shing Faculty of Medicine, The University of Hong Kong, has adopted a hybrid PBL undergraduate medical curriculum. We admit students from high school leavers with median age of 19 years. Students begin their PBL tutorials at the beginning of year 1 in the Introductory to Health and Disease (IHD) block followed by Respiratory, Cardiovascular, and Gastro-Intestinal Blocks. In year 2, PBL tutorials continue in the Urogenital, Musculoskeletal, Central Nervous System, Haematology/Immunology, and Endocrine Blocks. There are two formative assessment held in the 11-week IHD block. All other blocks are of 4 weeks duration with only a summative assessment at the end of the block.

According to Swanson's classification (1991), the assessing instruments can be categorized as outcome-oriented and process-oriented. Outcome-oriented instruments assess the product of students’ performance rather how results were achieved. Since the approach of PBL emphasize metacognitive skills, e.g., responsibility for learning, collaborative learning, and the use of variety of learning resources, process-oriented assessment methods usually focus on one or more of these. For PBL, we have adopted process-oriented assessment, at the end of each system block, in which five areas of competency – participation, communication, preparation, critical thinking, and group skills – are measured.

Students’ performance scores were obtained from 127 first-year students who were admitted in 2006 and followed up till the end of 2007. The scores from the first to the last system block were analyzed. They show progressive and significant improvement in the PBL tutorials (p < 0.05, ANOVA). The overall student's scores at week 8 (first assessment), week 11 (second assessment), week 31(end of first year), and week 82 (end of second year) are 73.8, 77.1, 77.0, and 83.6, respectively. Scores on individual competency also demonstrated similar trend. Our data show that young Chinese's school leavers are able to adapt to PBL within the first three months of joining the medical school, and also make progress over the first two years. This suggests that PBL is an appropriate pedagogy for the young Chinese learners.

L. C. Chan & P. S. L. Beh, Department of Pathology, The University of Hong Kong, University Pathology Building, Queen Mary Hospital Compound, Pokfulam Road, Hong Kong SAR, China. E-mail: [email protected]

A. L. M. Yip, Institute of Medical and Health Sciences Education, Li Ka Shang Faculty of Medicine, The University of Hong Kong, Hong Kong

Physiotherapy students’ perceptions of competences obtained through PBL methodology

Dear Sir

Immersed in the European Convergence process, the determination of the better activities to acquire competences is pre-eminent in Higher Education. The physiotherapy studies in our university, with previous experience with the problem-based learning methodology (PBL), designed a study with two objectives: (1) to explore physiotherapy students’ perceptions of the usefulness of a PBL activity based on a real case, compared with other learning methodologies and (2) to verify the students' perceptions of the transferable competences acquired through the PBL activity. The study was conducted during two consecutive academic years with third-year physiotherapy students of a core subject on advanced physiotherapeutic procedures. PBL methodology based on real clinical cases was applied during the first semester, while other learning methods were used during the second semester. The students in both courses agreed that there were no significant differences in the amount of learning achieved by the different teaching techniques. Nevertheless, PBL methodology was perceived more interesting than other activities. The use of a real case was the factor that produced the greatest satisfaction among the students. The competences in which the most improvement was perceived were ethical commitment, interpersonal relationship skills, concern for quality and teamwork. To summarize, the use of real, opposed to paper clinical cases, was the characteristic that increased the interest of the PBL methodology (Dammers et al. 2001; Kumar & Kogut 2006) and was directly related with the transferable competences that students perceive as achieved: competences related to social skills and professional quality. These competences were more relevant for the students that other competences as information management, capacity for analysis or critical thinking skills, showing the student's perspective of the competences that more approximate their future profession. ¹This knowledge may help the professor when planning accurate activities to obtain specific competences and to the academic staff planning curriculum development along the student education, hence this joint planning will allow decisions as to the best types of competences to work on in each course and the most suitable teaching methodologies for acquiring them.

Inmaculada Riquelme & Olga Velasco, Department of Nursing and Physiotherapy, University of the Balearic Islands, Palma de Mallorca, Spain. E-mail: [email protected]

Clinical performance assessment with five stations: Can it work?

Dear Sir

In clinical skills training, practical clinical performance assessment (CPA) is the method of choice to align teaching and learning. Scarcity of resources can force course designers to implement a CPA which does not meet the number of stations commonly suggested in the literature (e.g. Harden 1990). To break the scientific silence on CPA-compromise solutions, we investigate if and how a five-station CPA, meeting OSCE's essential elements (sampling, standardized rating), works in terms of validity, reliability and justifiability. Data from n = 694 students, each given five tasks selected semi-randomly from a pool of 26 (to ensure exam's validity for each student), is analyzed. The partial-credit-model (being a probabilistic model established in educational testing programs) was chosen as the psychometric framework with which to address the issues of construct validity and reliability, because it is well equipped to deal with incomplete data.

The psychometric quality of the 26 tasks is satisfying, indicating construct validity. Overall reliability is low (Rel_PS-empirical = 0.38) which was expected, but adequate for medium score groups (Rel_PS-empirical = 0.56/0.57, which is very close to what can be achieved with a five-station/three-category test; Rel_{PS-theoretical} = 0.60 (Linacre 1993)). A justifiable pass/fail decision (95% CI) can be made for 484 students (70%), but not for 210 students (30%) performing close to the pass/fail criterion. In every test there exists a group for whom a justifiable pass/fail decision cannot be made, but the higher the reliability, the smaller this group will be. For example, a 20-item CPA will result in a Rel_{PS-theoretical} between 0.80 and 0.90 and 70 students (10%) performing near the pass/fail criterion, where a decision is still not justifiable (95% CI).

Our research shows that educators can achieve a lot by conducting a five-station CPA to accommodate available resources. A justifiable pass decision is possible for the majority of the sample. The low test precision does result in a larger borderline-group with no justifiable pass/fail decision, but continued testing (up to 20 stations) only for this 30% eases budget strain, and diminishes the borderline group. No matter the test length, some students without a justifiable pass/fail decision will remain.

Thus, implementing three short CPAs in the course of a medical curriculum instead of one 20-station CPA once in a curriculum might be an option with long-lasting effect on valid teaching, learning and assessment of clinical skills.

Michaela Wagner-Menghin, Ingrid Preusche & Michael Schmidts, Department for Medical Education, Medical University of Vienna, Spitalgasse 23, BT87, A-1090 Vienna, Austria. E-mail: [email protected]

Online peer mentoring scheme for medical students

Dear Sir

I am writing to report the findings of an online peer-mentoring system for undergraduate medical students (MS) in the United Kingdom.

Peer mentoring in academic medicine has been associated with “increased research activity, increased retention in academic medicine, and increased career satisfaction” (Moss et al. 2008). However, there is little research on the benefits of peer mentoring for MS.

The aim of the scheme was to provide academic support and advice to MS throughout their first undergraduate year, via electronic communication.

Fifteen MS enrolled on the scheme in October 2009 and I was the sole advisor. I was contacted on average twice a month by each student, over the period of one academic year via email. I would aim to reply to their questions within one week, using text books, web-based resources, and lecture notes that I had compiled during my first year at university.

At the end of the scheme, I provided a questionnaire to the MS and achieved a 100% response rate. Using a 5-point Likert scale, 93% (n = 14) of the students strongly agreed with the statement, “This scheme has been useful in helping me through my first year of medical school”. 100% (n = 15) of students agreed that they would enrol in the scheme again and recommend it to other first year MS.

The next phase of the project is to enrol more student mentors to increase the size of the scheme. For the next academic year, following student feedback, a syllabus is being developed, relevant to pre-clinical years and administration of a pre-enrolment and post-scheme test to monitor student's progress will be put in place.

The scheme carries the advantage of being accessible to all medical students at universities throughout the UK as communication is entirely via email and enrolment is free.

James O’Donovan, 3rd Year Medical Student, Newcastle University, Newcastle-upon-Tyne NE2 4HH, UK. E-mail: james.o'[email protected]

A Questionnaire survey on sleeping in class phenomenon among Chinese medical undergraduates

Dear Sir

Sleep-related issues have always drawn much attention and been widely documented, but those in which the main subjects were undergraduates remain seldom researched. Sleeping in class is still a common phenomenon among universities in China. In our study, all 1693 undergraduates in a Medical University of China were surveyed with a self-administered anonymous questionnaire and 1640 valid results were collected (96.9%), including 1350 male and 290 female (average age 20.571 ± 1.512 years). Grades distribution: first-year undergraduates 546, second-year 575, third-year 488 and fourth-year 31. The content of the questionnaire included general conditions of the participants, self-reported sleeping in class incidences and causes, etc. Results showed that over 90% of the undergraduates had the experience of sleeping in class. The situations with both different genders (χ²= 42.734, p < 0.001) and different grades (χ²= 29.204, p < 0.05) had statistical differences. The percentages of often sleeping in class in males and females were 20.3% and 8.8%, respectively. And that in the first-r, second-, third- and fourth-year undergraduates were 16.0%, 17.0%, 22.2% and 19.4%, respectively. The reasons were successively fatigue (51.45%), academic dullness (18.4%), unqualified teaching (12.4%), great stress (8.5%), failure in understanding (4.8%), etc. This survey demonstrated that the problem of medical undergraduates sleeping in class is not unusual but in fact common in China. The percentage of males was higher than that of females. The higher grade the undergraduates were in, the higher the percentage was, except for fourth-year undergraduates (all were Master–Ph. D program undergraduates). Taken the causes together, we conclude that lightening psychological burden, cultivating study interests, advancing teaching levels (Van Berkel & Dolmans 2006) and carrying on teaching reforms, etc., are all effective measures to decrease the sleeping in class phenomenon.

J. Lu, G.E. Fang, S.J. Shen & Y. Wang, Training Department, Second Military Medical University, Shanghai, People's Republic of China. E-mail: [email protected]

Q. Sun, Department of Basic Medicine, Second Military Medical University, Shanghai, People's Republic of China

A Questionnaire survey on sleeping in class phenomenon among Chinese medical undergraduates

Dear Sir

Sleep-related issues have always drawn much attention and been widely documented, but those in which the main subjects were undergraduates remain seldom researched. Sleeping in class is still a common phenomenon among universities in China. In our study, all 1693 undergraduates in a Medical University of China were surveyed with a self-administered anonymous questionnaire and 1640 valid results were collected (96.9%), including 1350 male and 290 female (average age 20.571 ± 1.512 years). Grades distribution: first-year undergraduates 546, second-year 575, third-year 488 and fourth-year 31. The content of the questionnaire included general conditions of the participants, self-reported sleeping in class incidences and causes, etc. Results showed that over 90% of the undergraduates had the experience of sleeping in class. The situations with both different genders (χ²= 42.734, p < 0.001) and different grades (χ²= 29.204, p < 0.05) had statistical differences. The percentages of often sleeping in class in males and females were 20.3% and 8.8%, respectively. And that in the first-r, second-, third- and fourth-year undergraduates were 16.0%, 17.0%, 22.2% and 19.4%, respectively. The reasons were successively fatigue (51.45%), academic dullness (18.4%), unqualified teaching (12.4%), great stress (8.5%), failure in understanding (4.8%), etc. This survey demonstrated that the problem of medical undergraduates sleeping in class is not unusual but in fact common in China. The percentage of males was higher than that of females. The higher grade the undergraduates were in, the higher the percentage was, except for fourth-year undergraduates (all were Master–Ph. D program undergraduates). Taken the causes together, we conclude that lightening psychological burden, cultivating study interests, advancing teaching levels (Van Berkel & Dolmans 2006) and carrying on teaching reforms, etc., are all effective measures to decrease the sleeping in class phenomenon.

J. Lu, G.E. Fang, S.J. Shen & Y. Wang, Training Department, Second Military Medical University, Shanghai, People's Republic of China. E-mail: [email protected]

Q. Sun, Department of Basic Medicine, Second Military Medical University, Shanghai, People's Republic of China

Free and for-purchase ebooks of novels with public health themes

Dear Sir

The sale of ebook reading devices has recently increased along with the range of available ebooks. The quality of the reading devices also appears to be improving. These developments stimulated us to prepare a list of ebooks of novels that could potentially be used in medical education in the field of public health.

Our search strategy for potential novels included databases of literature and medicine (New York University School of Medicine) and literature and science (Rohm), a key text (Singer & Singer 2005), articles identified in a search of Medline and a hand search of the journal Medical Humanities. We also reflected on our personal book collections and past reading of literature and discussions with colleagues.

From these searches a list of 74 potential novels with significant public health themes were identified. We then performed further checks to determine ebook availability status by searching six ebook websites to identify availability as of July 2010. A full list of the novels considered by us are detailed in an online report (Wilson et al. 2010).

Of the novels identified, 62% (46/74) were available in ebook format. Of these, 61% (28/46) were available as free ebooks and 39% (18/46) were available for purchase (usually <$US 10). We further screened the novels from available online reviews and descriptions (e.g., those in the online databases detailed above, Wikipedia and Amazon.com). We also read 80% (37/46) of those available as ebooks (i.e., read by at least one team member). Then based on this information, we selected what we regarded as the five with the strongest public health themes in each category (free or pay).

Our five top free ebook novels with the strongest public health themes were: “A Journal of the Plague Year” (Defoe), “Arrowsmith” (Lewis), “Middlemarch” (Eliot), “North and South” (Gaskell), and “The Jungle” (Sinclair). Our five top ebook novels that were only available for purchase were: “The Runaway Jury” (Grisham), “The Cobra Event” (Preston), “The Constant Gardener” (Le Carré), “Down and out in Paris and London” (Orwell), and “Solar” (McEwan). Collectively, these novels cover a broad range of themes including infectious diseases, tobacco, poverty, social justice and climate change. The next step is for such ebooks to be evaluated in terms of acceptability to medical students (e.g., for reading during their public health run or holiday reading) and their value in improving and understanding of public health and social epidemiology.

Nick Wilson* & Philippa Howden-Chapman, Department of Public Health, University of Otago, Wellington, New Zealand. E-mail: [email protected]

Anne Tucker, Whitirea Polytechnic, Wellington, New Zealand

Susannah Fullerton, Jane Austen Society of Australia, Sydney, Australia