Humanizing medicine: a special study module

As medical schools begin to implement their new curricula under the guidance of Tomorrow's Doctors, the authors wish to raise some discussion on the form and content of the special study module (SSM) component. In order to do this they put forward in this paper proposals for an SSM in Medicine and Literature. This course has been designed jointly and will be run concurrently in three Scottish medical schools: Glasgow, Aberdeen and Dundee. Arguments for the course's acceptability to faculties of medicine and to students are discussed and its inclusion in the curriculum in terms of its educational impact, skills training, effect on personal development and broadening of the student's perspective are justified. The course structure, content and assessment procedures are described and a reading list proposed. The General Medical Council points out that SSMs should be seen as opportunities for innovation and this course demands a different educational approach from the standard objectives-led approach of most medical education. A process-led model is more appropriate as it stresses the way that students develop while taking the course rather than the end point reached at its finish.     

Support and faculty mentoring programmes for medical students in Germany, Switzerland and Austria

OBJECTIVES: To study what is being done at German-speaking universities regarding the counselling and tutoring of students, we carried out a survey among the deans of medical faculties in Germany, Austria and Switzerland. Our main concern was if any such projects were already available to the medical student or whether efforts to this purpose were under way. DESIGN: We focused in particular on faculty mentoring programmes, a continuous tutoring by designated members of the faculty on a person-to-person basis. SETTING: German, Austrian and Swiss medical faculties. SUBJECTS: Medical faculty deans. RESULTS: The return rate was 80%. While general student counselling is, if required, available at nearly all of the faculties, faculty mentoring programmes are offered by only 36.1% of the medical schools, and individualized career counselling by 30.6%. CONCLUSIONS: Compared to other countries, such as the United Kingdom or the United States, counselling and tutoring programmes, e.g. career planning or faculty mentoring, are not generally available to the German medical student. Regional differences are evident, which can be attributed to differences in the universities' legal and financial situation. The medical faculties at German-speaking universities should make it their priority to offer these services to the student on a permanent basis.     

The relation between understanding and practice in problem-based medical education

The importance of conceptions of the soundness of medical education are considered briefly. This leads to the question of misconceptions. A pervasive misconception characterized by the separation of understanding from action and practice, illustrated by two examples from the literature on medical education, is discussed. Questions as to the soundness of medical education are usually approached in terms of empirical inquiry; this paper takes a different, complementary, approach. Five medical faculties in Australia, Sweden and the UK. Problem-based medical course staff and students. The practical effect of the separation between action and practice is illustrated in the question of problem-solving as conceived in transitional semiproblem-based curricula in common with traditional curricula, limiting the development of sound professional education. The centrality of the misconception generates a widespread approach to the curriculum, described as the 'Convenient peg' model. In contrast, the 'Growing web' model enables the design of rigorous problem-based curricula which acknowledge that action and practice are necessarily related to understanding in a way unrecognized in the 'Convenient peg' model. Consequently, rigorous problem-based curricula embody a thoroughly integrated curriculum enabling improved medical education.     

Effectiveness of basic clinical skills training programmes: a cross-sectional comparison of four medical schools

OBJECTIVE: Training in physical diagnostic skills is an important part of undergraduate medical education. The objective of this study was to study the outcome of skills training at four medical schools. CONTEXT: At the time of the study, three schools had a traditional lecture-based curriculum and one school had a problem-based learning curriculum with a longitudinal skills training programme. All schools offer extended exposure to clerkships. METHOD: A cross-sectional study in four medical schools was performed, using a written test of skills that has good correlation with actual student performance. The scores attained from four student groups were compared within and between the four medical schools. A total of 859 volunteer students from the later four years at each medical school participated in the study. RESULTS: The mean scores in the traditional medical schools increased with the start of skill training and the hands-on experience offered during the clerkships. Students from the school with the longitudinal skills training programme and the problem-based learning approach had significantly higher mean scores at the start of the clerkships, and maintained their lead in the subsequent clinical years. CONCLUSIONS: Longitudinal skills training seems to offer the students a superior preparation for clerkships as well as influencing the students' learning abilities during the clerkships. The effect of the problem-based learning approach, also related to the innovative philosophy of the curriculum, could not be accounted for.     

A lesson from the introduction of a problem-based, graduate entry course: the effects of different views of self-direction

OBJECTIVES: Difficulties in the early years of a new curriculum are to be expected as staff and students come to terms with new structures, and with different approaches to teaching and learning. During the first year of implementation of the Graduate Medical Course at the Graduate School of Medicine, The University of Queensland, we experienced our share of 'teething troubles'. One source of difficulty was different interpretations of the concept of 'self-directed learning' as it was to be applied in the new course. This paper presents an analysis of the effects of these differences on the development of the curriculum. DESIGN: An orientation programme was designed to introduce students to staff, facilities and the PBL process. SETTING: The University of Queensland. SUBJECTS: Problem-based learning (PBL) tutors, medical students. RESULTS: The overall effect was to place in jeopardy the achievement of student self-direction and commitment to lifelong learning as a goal of the course. To counter the undesirable effects of different interpretations, we have developed a conceptual framework to promote an agreed understanding of the meaning of self-direction, and to guide review and further development of the curriculum. A further paper describes the framework. CONCLUSIONS: Consistency in interpretation of key concepts is an important factor in the success of problem-based curricula.     

Marginalisation of dental students in a shared medical and dental education programme

Objectives  Internationally, there are a number of universities at which medical and dental education programmes share common elements. There are no studies about the experiences of medical and dental students enrolled in different programmes who share significant amounts of learning and teaching.
Methods  Semi-structured interviews and focus groups were conducted with 36 students and staff in a learning programme shared between separate medical and dental faculties. They were transcribed and an iterative process of interpretation and analysis within the theoretical framework of the contact hypothesis and social identity theory was used to group data into themes and sub-themes.
Results  Dental students felt 'marginalised' and felt they were treated as 'second-class citizens' by medical students and medical staff in the shared aspects of their programmes. Contextual factors such as the geographical location of the two schools, a medical : dental student ratio of almost 3 : 1, along with organisational factors such as curriculum overload, propagated negative attitudes towards and professional stereotyping of the dental students. Lack of understanding by medical students and faculty of dental professional roles contributed further.
Conclusions  Recommendations for reducing the marginalisation of dental students in this setting include improving communication between faculties and facilitating experiential contact. This might be achieved through initiating a common orientation session, stronger social networks and integrated learning activities, such as interprofessional problem-based learning and shared clinical experiences.     

Social issues in medicine: a follow-up comparison of senior-year medical students'' attitudes with contemporaries in non-medical faculties

A comparison of first-year medical students' attitudes to social issues in medicine with attitudes of non-medical first-year students in 1983 found that the medical group was less conservative towards general social issues but more conservative in relation to those areas which closely affect the doctor's role, particularly the place of allied health professions and government intervention in health care. This paper reports a follow-up study of the same groups of students when they had reached senior years in their respective courses. While medical student conservatism on general social issues continues to be no greater than other student groups there is a marked increase in conservatism of attitudes towards government involvement in health care and regulation of costs. Attitudes to allied health professions and preventive care remain unchanged but senior medical students are significantly less likely to recognize social factors as determinants of illness than they were when they commenced the study of medicine. Specific curricular attention to social and behavioural medicine does not appear to counteract the predominantly biomedical perspective students experience in teaching hospitals, the major venue for their clinical education.     

The cost of problem-based vs traditional medical education

It is generally accepted that teachers' salaries are a major factor in the cost of medical education. Little is known about the effects of curriculum on teaching time. A comparison of teaching time devoted to each of two different medical education curricula is presented. In a traditional teacher-centered, subject-oriented curriculum, 61% of the total teaching effort expended by twenty-two teachers took place in the absence of students, i.e. in preparation for student contact. Only 39% of the effort devoted by these teachers to medical education took place in the presence of students. In a problem-based, student-centered curriculum which focuses upon small-group tutorial learning and early extended primary care experience in a rural community setting, 72% of the total teaching effort devoted to medical education was spent with students and only 28% was spent in preparation for student contact. Overall, there were no differences in the total amount of teaching time required by each of the two curricular approaches to medical education. There were, however, major differences in how teachers spent their teaching time.     

Medical students' essay-writing skills: criteria-based self- and tutor-evaluation and the role of language background

OBJECTIVES: An exercise is described which aimed to make clear to first-year undergraduate medical students the expected writing skills required for an essay examination in one discipline. SUBJECTS: Many students were from a non-English speaking background and over one-third of students, regardless of language background, had limited experience in this type of essay writing. PROCEDURE: For this exercise, a practice essay was written by each student for formative assessment. The essay was rated by a tutor and by the student according to well-defined criteria. This allowed for comparisons to be made in a structured and objective way between the judgements of the student and the assessor. RESULTS: Students found the exercise to be very useful, although whether essay writing skills actually improved could not be established. Students from non-English speaking backgrounds tended to be most harsh in their self-evaluations, yet tutor-evaluations generally showed these students to have better writing skills than other students. Indeed, correlations between self- and tutor-evaluations were quite low. CONCLUSIONS: It is evident that students and their educators may be unclear about each others' expectations. By making explicit the requirements of an exercise, misunderstandings may be minimized and it is possible that student performance could improve, though further research is required to verify these hypotheses. It is suggested that students should be encouraged to evaluate their own work and should be instructed in writing skills throughout their medical degree education.     

Providing early clinical experience in primary care

Undergraduate courses in British medical schools are changing following recommendations from the General Medical Council. Increasing emphasis has been placed on teaching in the community. Nottingham Medical School has pioneered the teaching of basic clinical skills in primary care during the pre-clinical course to help produce an integrated curriculum. This qualitative study evaluated the first two years of the new early clinical experience course at Nottingham by using interviews with 19 students and their GP tutors. Students claimed to have gained confidence in talking to patients, their understanding of the role of the doctor and the importance of the doctor-patient relationship. Students were less confident about examining patients and some reported having had little opportunity to practice examination skills. Half the students thought that the early clinical visits had helped them to understand and be more motivated to learn their basic medical sciences course. The newly recruited GP teachers were highly motivated, very positive about the early clinical teaching and all wanted to continue to teach the pre-clinical students. Difficulties in providing the course included communication with students and staff, organization of student travel and variation in the quality of teaching. However, the Nottingham early clinical experience course has shown that basic clinical skills can be successfully taught to pre-clinical students in primary care.     

Towards more empathic medical students: a medical student hospitalization experience

OBJECTIVE: We designed a curricular exercise intended to expose healthy medical students, near the end of their basic science training, to the experience of hospitalization. We attempted to assess how a standardized hospitalization, for medical students just about to start their clinical rotations, was experienced by student participants. DESIGN: A qualitative observational design was used, both to explore the perceptions of the hospitalized students and to generate hypotheses for further exploration. SETTING: University and affiliated hospitals. PARTICIPANTS: Second-year medical students, towards the end of their basic science training. OUTCOME MEASURES: Qualitative assessment of hospitalization experience. RESULTS: Among key themes expressed by student participants were the following: they felt a profound loss of privacy; they found the nursing staff to be caring, attentive and professional, and repeatedly commented about how much time the nurses took to talk and listen to them and to take a complete history; in contrast they were particularly upset about the distance and coldness they felt from the medical staff; they expect this experience to affect their own future practice as physicians. When asked how this might change their attitudes in the future, students' comments generally reflected a primary concern with improving the human aspects of the patient experience. CONCLUSIONS: Student participants in a standardized inpatient hospitalization generally experienced strong feelings about issues of privacy, and about interactions with medical and nursing staff, which they expect to have an important impact on their own professional development.     

Structured packs for independent learning: a comparison of learning outcome and acceptability with conventional teaching

OBJECTIVES: The GMC recommends that students become independent learners, while tutor time is an increasingly precious resource. A set of structured learning materials requiring students to undertake and reflect on practical tasks in five learning areas was developed. DESIGN: The study used a randomized control trial to evaluate the effectiveness of using these structured learning materials in place of conventional teaching for 228 third-year undergraduate students and 55 teachers, on both hospital and community based medical and general practice firms. Evaluation involved assessing student performance on an examination question and a writing task, together with a student and tutor satisfaction questionnaire. SETTING: King's College School of Medicine and Dentistry, London. SUBJECTS: Third-year medical (first-year clinical) undergraduates. RESULTS: No significant difference in learning outcome was found for students on community- and hospital-based medical and general practice firms between students who had used the structured materials and those who had had conventional teaching on the same topic. The packs were acceptable to tutors and students. CONCLUSIONS: Such resources represent a mid-point between formal didactic teaching and self-directed learning. They may be particularly suitable for promoting independent learning for students on traditional medical courses. They offer an appropriate way to cover certain topics in the clinical curriculum and help to protect tutor time for topics which cannot be effectively taught in other ways.     

Can student tutors act as examiners in an objective structured clinical examination?

Context  The dissemination of objective structured clinical examinations (OSCEs) is hampered by requirements for high levels of staffing and a significantly higher workload compared with multiple-choice examinations. Senior medical students may be able to support faculty staff to assess their peers. The aim of this study is to assess the reliability of student tutors as OSCE examiners and their acceptance by their peers.
Methods  Using a checklist and a global rating, teaching doctors (TDs) and student tutors (STs) simultaneously assessed students in basic clinical skills at 4 OSCE stations. The inter-rater agreement between TDs and STs was calculated by kappa values and paired t -tests. Students then completed a questionnaire to assess their acceptance of student peer examiners.
Results  All 214 Year 3 students at the University of Göttingen Medical School were evaluated in spring 2005. Student tutors gave slightly better average grades than TDs (differences of 0.02–0.20 on a 5-point Likert scale). Inter-rater agreement at the stations ranged from 0.41 to 0·64 for checklist assessment and global ratings; overall inter-rater agreement on the final grade was 0.66. Most students felt that assessment by STs would result in the same grades as assessment by TDs (64%) and that it would be similarly objective (69%). Nearly all students (95%) felt confident that they could evaluate their peers themselves in an OSCE.
Conclusions  On the basis of our results, STs can act as examiners in summative OSCEs to assess basic medical skills. The slightly better grades observed are of no practical concern. Students accepted assessment performed by STs.     

Training and experience of examiners

Variation in the accuracy of examiner judgements is a source of measurement error in performance-based tests. In previous studies using doctor subjects, examiner training yielded marginal or no improvement in the accuracy of examiner judgments. This study reports an experiment on accuracy of scoring in which provision of training and background of examiners are systematically varied. Experienced teaching staff, medical students and lay subjects were randomly assigned to either training or no-training groups. Using detailed behavioural check-lists, they subsequently scored videotaped performance on two clinical cases, and accuracy of their judgments was appraised. Results indicated that the need for and effectiveness of training varied across groups: it was least needed and least effective for the teaching staff group, more needed and effective for medical students, and most needed and effective for the lay group. The accuracy of the lay group after training approached the accuracy of untrained teaching staff. Trained medical students were as accurate as trained teaching staff. For teaching staff and medical students training also influenced the nature of errors made by reducing the number of errors of commission. It was concluded that training varies in effectiveness as a function of medical experience and that trained lay persons can be utilized as examiners in performance-based tests.     

Comparing health care delivery systems – initiating a student exchange project between Europe and the United States

BACKGROUND: Cross-cultural contact among different health care systems can provide a framework for identifying the strengths and weaknesses of one's own healthcare system. However, such contact has rarely had much impact upon medical education curricula. Despite intense debate on reforming the healthcare delivery systems (HCDS) in Europe and the United States, there is very little formal representation of this interdisciplinary field in our educational programs. DESCRIPTION: To address this problem, a medical student exchange program was conducted in which students developed case studies that produced comparative analyses of HCDS in Germany, Sweden, Denmark and the United States. Each case is intended to highlight critical differences among the systems. EVALUATION: Students and their faculty preceptors completed pre- and post-exchange questionnaires to assess perceived knowledge of the HCDS and the adequacy of time devoted to it in their curricula. Both perceived that too little attention was devoted to this content in their programs. Following the exchange, students described clear increases in perceived knowledge. DISCUSSION: Our common interest in curriculum reform was key to implementing the exchange. The written cases generated by the students are being developed as course material in some of the schools and a conference is planned to disseminate the cases and the implementation strategies for their inclusion in medical curricula.     

Evaluation of undergraduate medical education in Finnish community-oriented and traditional medical faculties: a 10-year follow-up

OBJECTIVES: This study focused on Finnish physicians' views of their undergraduate medical education. Differences between traditional and community-oriented medical faculties were examined and changes which had taken place during a 10-year follow-up period were also assessed. METHODS: The study was based on data retrieved from a postal survey made among Finnish physicians in 1998. The study population consisted of all doctors who graduated between 1987 and 1996 (n=4926); those born on odd-numbered days were selected for this study (n=2492). A postal questionnaire and two reminders were sent to those selected, and 1822 questionnaires were returned, giving a response rate of 73.1%. RESULTS: Physicians who graduated from the community-oriented faculties were more satisfied with their undergraduate medical education when compared with their colleagues graduating from traditional faculties. There were some differences between the universities with respect to education for hospital work. The teaching of primary health care, however, was clearly more effective in community-oriented faculties. The proportion of graduates who were satisfied with their primary care education was over 70% in community-oriented faculties, whereas in the traditional faculties it was only 35-45%. CONCLUSIONS: According to graduates, the community-oriented medical school curriculum better meets the needs of practising physicians than that in traditional faculties. In curriculum reforms, more emphasis should be placed on comprehensive medical education, which includes both primary and secondary health care.     

Non-cognitive characteristics of medical students: entry to problem-based and lecture-based curricula

The effectiveness of problem-based learning (PBL) versus lecture-based learning (LBL) continues to be debated all over the world. These arguments have often been based on students' cognitive measures of performance. Little emphasis has been placed on non-cognitive factors that may directly or indirectly affect the medical school performance of students in either curriculum. The purpose of this study was to (1) document possible differences in student cognitive and non-cognitive characteristics at entry between the two curricula and (2) to explore the relationships that exist between cognitive and noncognitive factors. Data were obtained from three medical school classes (   n = 281  ). The results indicate that students who entered the PBL curriculum at this medical school had higher total Medical College Admission Test and undergraduate grade point average than students who entered the LBL curriculum. Students who entered the PBL curriculum were also more self-sufficient and were more likely to do well in individualistic and less structured settings. There were no strong correlations between cognitive and non-cognitive variables. Before conclusions can be drawn about the effectiveness of either PBL or LBL curricula, we need to document patterns in entry characteristics to control for a priori differences that affect student performance.     

Patient-centred medicine through student-centred teaching: a student perspective on the key impacts of community- based learning in undergraduate medical education

CONTEXT: The UK General Medical Council has proposed that increased use of community settings is essential to enhancement of medical education. However, such curriculum developments have been directed by educationalists and clinical faculty; there is to date little to show whether student perspectives accord with such expectations. AIM: To examine student views on whether community-based learning during a UK undergraduate medical education course results in new learning in the areas expected, and to elucidate any process factors which enhance attainment of learning objectives. METHOD: Nominal group technique, to develop consensus on important learning outcomes and process factors, and questionnaire survey, developed from the views of the nominal groups. RESULTS: 89 students participated (response rate 70% for the nominal groups, and 88% for questionnaire). Students perceived increased learning in many of the areas expected. In particular, students reported significant learning from: witnessing the impact of a longer term and more personal relationship with patients; the visible impact of social environment on health; the importance of dealing with people rather than diseases, and the use of the whole team for care. In addition, they emphasized that tutor, staff and patient enthusiasm for student presence and learning greatly enhanced the student learning experience. CONCLUSIONS: Community settings appear to achieve the expected attitudinal adaptation of students. The role of the committed tutor and team is seen as pivotal to learning. The conclusions support an increased emphasis in contemporary medical education and related research activity on the key impact of relationships in the learning environment.