Living with 'melanoma' for a day: a phenomenological analysis of medical students' simulated experiences.

BACKGROUND: Despite the rising incidence of melanoma, medical students have progressively fewer opportunities to encounter patients with this important condition. Curricula tend to attach the greatest value to intellectual forms of learning. However, compared with intellectual learning, experiential learning affords students deep insights about a condition. Doctors who experience ill health are more empathic towards patients. However, opportunities to learn about cancer experientially are limited. Temporary transfer tattoos can simulate the ill health associated with melanoma. We reasoned that if doctors who have been sick are more empathic temporarily 'having' melanoma might have a similar effect. OBJECTIVES: To explore the impact of wearing a melanoma tattoo on medical students' understanding of patienthood and attitudes towards patients with melanoma. METHODS: Ten fourth-year medical students were recruited to a simulation. They wore a melanoma tattoo for 24 h and listened to a patient's account of receiving their diagnosis. Data were captured using audio diaries and face-to-face interviews, transcribed and analysed phenomenologically using the template analysis method. RESULTS: There were four themes: (i) melanoma simulation: opening up new experiences; (ii) drawing upon past experiences; (iii) a transformative introduction to patienthood; (iv) doctors in the making: seeing cancer patients in a new light. CONCLUSIONS: By means of a novel simulation, medical students were introduced to lived experiences of having a melanoma. Such an inexpensive simulation can prompt students to reflect critically on the empathetic care of such patients in the future.

How do clinicians become teachers? A communities of practice perspective.

There is widespread acceptance that clinical educators should be trained to teach, but faculty development for clinicians is undermined by poor attendance and inadequate learning transfer. As a result there has been growing interest in situating teacher development initiatives in clinical workplaces. The relationship between becoming a teacher and clinical workplace contexts is under theorised. In response, this qualitative research set out to explore how clinicians become teachers in relation to clinical communities and institutions. Using communities of practice (CoP) as a conceptual framework this research employed the sensitising concepts of regimes of competence and vertical (managerial) and horizontal (professional) planes of accountability to elucidate structural influences on teacher development. Fourteen hospital physicians completed developmental timelines and underwent semi-structured interviews, exploring their development as teachers. Despite having very different developmental pathways, participants' descriptions of their teacher identities and practice that were remarkably congruent. Two types of CoP occupied the horizontal plane of accountability i.e. clinical teams (Firms) and communities of junior doctors (Fraternities). Participants reproduced teacher identities and practice that were congruent with CoPs' regimes of competence in order to gain recognition and legitimacy. Participants also constructed their teacher identities in relation to institutions in the vertical plane of accountability (i.e. hospitals and medical schools). Institutions that valued teaching supported the development of teacher identities along institutionally defined lines. Where teaching was less valued, clinicians adapted their teacher identities and practices to suit institutional norms. Becoming a clinical educator entails continually negotiating one's identity and practice between two potentially conflicting planes of accountability. Clinical CoPs are largely conservative and reproductive of teaching practice whereas accountability to institutions is potentially disruptive of teacher identity and practice.

Exodus? The training paths and plans of postgraduate medical trainees, under the Royal College of Physicians of Ireland.

BACKGROUND: In 2006, the Buttimer report highlighted the paucity of demographic data on those applying for and entering postgraduate medical education and training (PGMET) in Ireland. Today, concerns that there is an "exodus" of graduates of Irish medical schools are at the forefront of national discussion, however, published data on PGMET remains inadequate. AIMS: The objectives of this study were to collate existing data relating to trainees and training programmes at three stages of training and to examine the career plans of junior trainees. METHODS: Data from application forms for training programmes, commencing July 2012, under the Royal College of Physicians of Ireland (n = 870), were integrated with data from other existing sources. Candidates entering basic specialist training were surveyed with regard to career plans. Descriptive and comparative analysis was performed in SPSS version 18. RESULTS: Graduates of Irish medical schools made up over 70 % of appointees. Over 80 % of BST trainees aspired to work as consultants in Ireland, but 92.5 % planned to spend time working abroad (response rate 77 %). Decisions to leave the Irish system were linked to lifestyle, but also to failure to be appointed to higher specialist training. Significant numbers of trainees return to Ireland after a period abroad. CONCLUSIONS: The trainee "exodus" is more complex than is often portrayed. The desire to spend time working outside Ireland must be accounted for in workforce planning and configuration of training programmes. Expansion of HST is a potential solution to reduce the numbers of graduates leaving Ireland post-BST.

Postgraduate training in Ireland: expectations and experience.

BACKGROUND: Postgraduate medical training in Ireland has been compared unfavourably with training abroad and blamed for an "exodus" of graduates of Irish medical schools. Exploration of features of a good training environment and development of tools to measure it have been the focus of much published research. There have been no Irish studies examining training environment using such validated tools. AIM: The aim of this study was to use a validated tool, to examine the expectations and experience of training, amongst those training under the Royal College of Physicians of Ireland (RCPI). METHOD: The Dutch Residency Education Climate Test (D-RECT) is a 50 item tool to measure postgraduate learning environments. D-RECT was sent to all new entrants to RCPI training programmes in July 2012 (n = 527) and completed in regard to expectations of training (response rate 80.6 %). In March 2013, D-RECT was sent to all RCPI trainees (n = 1,246) to complete in relation to the post held on 1 March (response rate 32.6 %). Data were analysed in SPSS version 18. RESULTS: Experience fell short of expectations for basic specialist training, however, scores for experience rose with greater seniority to match expectations. Positive aspects were teamwork, consultant willingness to discuss patients and respectful treatment of trainees. Areas of weakness were provision of feedback and time to learn new skills. CONCLUSION: Measurement of learning environment at a national level using a quantitative tool provides useful information for quality assurance and improvement of training.

Making sense of how physician preceptors interact with medical students: discourses of dialogue, good medical practice, and relationship trajectories.

Work based learning and teaching in health care settings are complex and dynamic. Sociocultural theory addresses this complexity by focusing on interaction between learners, teachers, and their environment as learners develop their professional identity. Although social interaction between doctors and students plays a crucial role in this developmental process, socio-cultural research from the perspective of doctors is scarce. We performed discourse analysis on seven general practitioners' audio diaries during a 10-week general practice clerkship to study how they gave shape to their interaction with their students. Examination of 61 diary-entries revealed trajectories of developing relationships. These trajectories were initiated by the way respondents established a point of departure, based on their first impression of the students. It continued through the development of dialogue with their student and through conceptualizations of good medical practice. Such conceptualizations about what was normal in medical and educational practice enabled respondents to recognize qualities in the student and to indirectly determine students' desired learning trajectory. Towards the end, discursive turns in respondents' narratives signaled development within the relationship. This became evident in division of roles and positions in the context of daily practice. Although respondents held power in the relationships, we found that their actions depended strongly on what the students afforded them socially. Our findings address a gap in literature and could further inform theory and practice, for example by finding out how to foster constructive dialogue between doctors and students, or by exploring different discourses among learners and teachers in other contexts.

The influence of reflection on portfolio learning in undergraduate dental education.

INTRODUCTION: Disparity exists between the growing consensus about the positive effects of reflection on performance and the scarcity of empirical evidence demonstrating this effect. Portfolios are considered a useful instrument to assess and supervise competence-based education and to stimulate reflection. The present study describes the introduction of a portfolio in a social dentistry and oral health promotion course and investigates student reflection as a predictor for the acquisition of the other competences in the course. METHODS: Fourth year undergraduate dental students (n = 110) in the course 'Society and Health' between 2008 and 2011 collected evidence in their portfolios, demonstrating the acquisition of five competences: the ability to (1) assess the oral health profile of a target group; (2) integrate theoretical models in health promotion; (3) search for and apply scientific evidence; (4) work trans-, multi- and/or trans-disciplinarily; (5) reflect on personal development. Linear regression analysis was used to investigate the predictive value of reflection on the other course related competences. RESULTS: Reflection scores proved to significantly predict other course-related competences, when analysing all students between 2008 and 2011 and for each year separately, explaining between 10.7% and 25.5% of the variance in the other competences. CONCLUSION: Undergraduate dental students' competences related to social dentistry and oral health promotion were significantly predicted by the reflection scores obtained in a portfolio-based context. In line with the growing consensus about the benefits of reflection for dental students and professionals, results suggest the value to further develop the integration of reflection in dental education and practice.

Attachment style and alliance in patients with diabetes and healthcare professionals.

Avoidant attachment has been found to impair attendance at appointments and treatment adherence of patients with diabetes, but the role of staff-patient relationships has not been explored. This study investigates whether attachment influences the quality of alliance between patients with diabetes and healthcare professionals. Patient avoidance was significantly associated with difficulties in therapeutic alliance. Further research is required to establish whether therapeutic alliance, underpinned by attachment, influences treatment adherence and to investigate ways of promoting collaboration.

Development and evaluation of an e-learning package for teaching skin examination. Action research.

BACKGROUND: Dermatology is one of many specialities competing for space in the undergraduate curriculum, and recent review reveals that in some medical schools only a minority of students receives direct teaching from dermatologists. Enlargement of medical schools and dispersion of students over multiple sites further increase the strain on teaching resources. OBJECTIVES: To develop and obtain 'proof of concept' for a technology to teach skin examination, using an approach grounded in modern theories of learning. METHODS: The requirements for an e-learning technology were identified through literature review and qualitative analysis of stakeholders' requirements with respondent and expert validation. A method of teaching skin examination was developed by applying Anderson's theory of skills acquisition. It was prototyped first on paper, then electronically, and its usability as an instructional tool was evaluated. RESULTS: The project delivered, firstly, a specification for skin examination derived from published evidence, textbook content, and staff and student consensus; and secondly, a very useable technology to help students learn skin examination (http://www.skillsbase.man.ac.uk). A validation task was completed in 20 min without significant usability problems, and evaluators found it simple, intuitive, interactive and enjoyable to use. Students saw it as an adjunct that would help them build confidence and revise for examinations. Nonstakeholder teachers expressed concern about the apparent simplicity of its contents and felt that it should only be used in association with traditional teaching methods. CONCLUSIONS: Students, educationalists and teachers were able to codesign a useable skin examination package, which merits evaluation of efficacy. In view of the logistic difficulties of teaching dermatology to the growing student population, the technology may be a useful adjunct to traditional teaching methods. Our approach may inform further developments in educational technology in dermatology.

The diabetes educator: trying hard, but must concentrate more on behaviour.

Current guidelines state that education is fundamental to help people with diabetes modify their lifestyle and prevent ill health and early death. However, many people with diabetes are not receiving adequate education. There is a widespread assumption that transferring knowledge will improve health outcomes but there is little empirical support for this assertion. Indeed, knowledge and behaviour are poorly correlated. Knowledge may be a necessary condition but is rarely a sufficient condition for behaviour change. Single interventions, cognitive or behavioural, have had disappointing results, unsurprisingly given the complexity of human behaviour. The most effective interventions are multifaceted and include education, behavioural and psychosocial elements, and target lifestyle change and factors such as self-efficacy and empowerment. We advocate that educational interventions should have multiple components. They should aim to improve patients' sense of self-efficacy and empowerment, and build attitudes towards diabetes that will support the lifestyle changes needed for successful self-management. These conclusions have implications for future research and clinical practice.

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review.

REVIEW DATE: Review period January 1992-December 2001. Final analysis July 2004-January 2005. BACKGROUND AND REVIEW CONTEXT: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. OBJECTIVES OF REVIEW: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research. SEARCH STRATEGY: Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of:Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology. EXPERIENCE: Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included. EXCLUSIONS: Not empirical; not early; post-basic; simulated rather than 'authentic' experience. DATA COLLECTION: Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation. HEADLINE RESULTS: A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention. CONCLUSIONS: Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Evaluation of self-directed clinical education: validation of an instrument.

AIM: To explore the evaluation of self-directed, integrated clinical education. METHODS: We delivered a quantitative and qualitative, self-report questionnaire to students through their web-based learning management system. The questionnaire was distributed 4 times over 1 year, each time in 2 parts. A generic part evaluated boundary conditions for learning, teaching activities and "real patient learning". Factor analysis with varimax rotation was used to validate the constructs that made up the scale and to stimulate hypotheses about how they interrelated. A module-specific part evaluated real patient learning of the subject matter in the curriculum. RESULTS: A total of 101 students gave 380 of a possible 404 responses (94%). The generic data loaded onto 4 factors, corresponding to: firm quality; hospital-based teaching and learning; community and out-patient learning, and problem-based learning (PBL). A 5-item quality index had content, construct and criterion validity. Quality differed greatly between firms. Self-evaluation of module-specific, real patient learning was also valid. It was strongly influenced by the specialty interests of hospital firms. CONCLUSIONS: Quality is a multidimensional construct. Self-report evaluation of real patient learning is feasible, and could be capitalised on to promote reflective self-direction. The social and material context of learning is an important dimension of educational quality.

How do people with Type 2 diabetes perceive and respond to cardiovascular risk?

OBJECTIVES: To explore how people with Type 2 diabetes perceive cardiovascular risk, and how those perceptions might affect their motivation to make lifestyle changes. METHODS: The setting was a diabetes clinic in a UK teaching hospital. A qualitative study was conducted, using semistructured individual interviews and template analysis of content. The participants were 20 Type 2 diabetic patients, aged between 52 and 77 years, half with and half without cardiovascular disease (CVD). RESULTS: Whether they had CVD or not, most people were aware they were at risk of it, of its causative factors, and possible effects. However, they were more likely to attribute it to unchangeable factors like 'stress' and 'heredity', than medical risk factors like cholesterol and smoking. Patients with pre-existing CVD correctly regarded their risk as higher than those without. Few saw any direct link between being diabetic per se and cardiovascular risk. Lifestyle changes were precipitated by major life events and motivated by family support, fear of complications, and a belief that one should follow doctors' advice. A common reaction to CVD and diabetes was stoical acceptance, allowing patients to view their lives positively, whilst living with unpredictable potentially disabling diseases. CONCLUSIONS: Patients were unaware how strongly diabetes influences cardiovascular risk. Their ideas about risk were very different from those of conventional medicine, and provided individual rationales for making choices about treatment and risk-influencing behaviour. Contextual factors, such as family milieu, also influenced their behaviour. Clinicians should not assume patients share the same mental model of risk as they, and must be prepared to explore peoples' individual constructs and health beliefs.

Child health and obstetrics-gynaecology in a problem-based learning curriculum: accepting the limits of integration and the need for differentiation.

BACKGROUND AND OBJECTIVES: The University of Manchester's undergraduate curriculum was reorganised in 1994. Problem-based learning (PBL) was chosen as the central educational method throughout the 5 years. A thematic interdisciplinary style provided a framework around which to select and integrate content. The theme for family, reproductive and child health for the 14-week Families and Children Module (FCM) in year 4 integrated content from obstetrics-gynaecology, paediatrics (including child psychiatry), genetics and public health. This paper focuses on the FCM which has put to test some of the principles of integration. METHODS: The educational process and outcome of the FCM was evaluated with information from (1) Open Forum feedback sessions (2) student questionnaires and (3) students' performance in an objective structured clinical examination (OSCE). RESULTS: Significant problems were encountered during the first year of the FCM (1997--98). An Open Forum for all students and staff was convened after each module in order to address the level of concern. Students' responses to questionnaires reflected the overall impression obtained from the Open Forum. Difficulties appeared to be more than the anxieties and challenges inherent in organisational change and were not simple practical timetabling problems. Tutors perceived a loss of coherence and student contact; students reported difficulties maintaining sufficient continuity of focus in clinical and academic learning experiences. The intended level of integration of paediatrics and obstetrics-gynaecology was unmanageable. Consequently, the FCM (1998-99) was divided into separate attachments for clinical learning and experience in paediatrics and obstetrics-gynaecology, each of 7 weeks' duration. Further open feedback sessions revealed that the modifications implemented in 1998-99 were associated with positive experiences for students and tutors. Comparison of responses to the evaluation questionnaires showed that students' overall rating of the module was higher (P=0.002) for 1998-99 (mean 3.4, SD 0.9) than for 1997-98 (mean 3.0, SD 1.1). CONCLUSIONS: We emphasise that horizontal integration can result in an experience of disintegration for students and tutors. Certain disciplines, such as paediatrics and obstetrics-gynaecology, may not have enough in common for full curriculum integration.