The development of a pragmatic, clinically driven ultrasound curriculum in a UK medical school.

Whether ultrasound (US) should be incorporated into a medical undergraduate curriculum remains a matter of debate within the medical education arena. There are clear potential benefits to its early introduction particularly with respect to the study of living anatomy and physiology in addition to the learning of clinical skills and procedures required for the graduate clinical practice. However, this needs to be balanced against what is perceived as an added value in addition to financial and time constraints which may potentially lead to the sacrifice of other aspects of the curriculum. Several medical schools have already reported their experiences of teaching US either as a standalone course or as a fully integrated vertical curriculum. This article describes and discusses the initial experience of a UK medical school that has taken the steps to develop its own pragmatic vertical US curriculum based on clinical endpoints with the intent of using US to enhance the learning experience of students and equipping them with the skills required for the safe practice as a junior doctor.

Qualitative and quantitative feedback in the context of competency-based education.

Research indicates the importance and usefulness of feedback, yet with the shift of medical curricula toward competencies, feedback is not well understood in this context. This paper attempts to identify how feedback fits within a competency-based curriculum. After careful consideration of the literature, the following conclusions are drawn: (1) Because feedback is predicated on assessment, the assessment should be designed to optimize and prevent inaccuracies in feedback; (2) Giving qualitative feedback in the form of a conversation would lend credibility to the feedback, address emotional obstacles and create a context in which feedback is comfortable; (3) Quantitative feedback in the form of individualized data could fulfill the demand for more feedback, help students devise strategies on how to improve, allow students to compare themselves to their peers, recognizing that big data have limitations; and (4) Faculty development needs to incorporate and promote cultural and systems changes with regard to feedback. A better understanding of the role of feedback in competency-based education could result in more efficient learning for students.

Trends in national licensing examinations in medicine.

CONTEXT: As a contribution to this special issue commemorating the journal's 50th volume, this paper seeks to explore directions for national licensing examinations (NLEs) in medicine. Increases in the numbers of new medical schools and the mobility of doctors across national borders mean that NLEs are becoming even more important to ensuring physician competence. OBJECTIVES: The purpose of this paper is to explore the use of NLEs in the future in the context of global changes in medical education and health care delivery. METHODS: Because the literature related to NLEs is so large, we have not attempted a comprehensive review, but have focused instead on a small number of topics on which we think we have something useful to say. The paper is organised around five predicted trends for NLEs. DISCUSSION: The first section discusses reasons why we think the use of NLEs will increase in the coming years. The second section discusses the ongoing problem of content specificity and its implications for the design of NLEs. The third section examines the evolution of large-scale, standardised cognitive assessments in NLEs and suggests some future directions. Reflecting the fact that NLEs are, increasingly, attempting to assess more than just knowledge, the fourth section addresses the future of large-scale clinical skills assessments in NLEs, predicting both increases in their use and some shifts in the nature of the stations used. The fifth section discusses workplace-based assessments, predicting increases in their use for formative assessment and identifying some limitations in their direct application in NLEs. The concluding section discusses the cost of NLEs and indulges in some further speculations about their evolution.

Assessing competencies using milestones along the way.

This paper presents perspectives and controversies surrounding the use of milestones to assess competency in outcomes-based medical education. Global perspectives (Canada, Europe, and the United States) and developments supporting their rationales are discussed. In Canada, there is a significant movement away from conceptualizing competency based on time, and a move toward demonstration of specific competencies. The success of this movement may require complex (rather than reductionist) milestones that reflect students' progression through complexity and context and a method to narrate their journey. European countries (United Kingdom, France, and Germany) have stressed the complexity associated with time and milestones for medical students to truly achieve competence. To meet the changing demands of medicine, they view time as actually providing students with knowledge and exposure to achieve various milestones. In the United States, milestones are based on sampling throughout professional development to initiate lifelong learning. However, the use of milestones may not imply overall competence (reductionism). Milestones must be developed alongside outcomes-based curriculum with use of faculty and competency committees. The perspectives outlined in this paper underscore emerging challenges for implementing outcomes-based medical education and call for new conceptualizations of competence.

Patient involvement in teaching and assessing intimate examination skills: a systematic review.

OBJECTIVES: There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety faced by novice learners. This systematic review provides a summary of the evidence for the involvement of real patients (RPs) and simulated patients (SPs) in the training of health care professionals in intimate examination skills. METHODS: For the review, 'intimate examinations' included pelvic, breast, testicular and rectal examinations. Major databases were searched from the start of the database to December 2008. The synthesis of findings is integrated by narrative structured to address the main research questions, which sought to establish: the objectives of programmes involving RPs and SPs as teachers of intimate examination skills; reasons why SPs have been involved in this training; the evidence for the effectiveness of such training programmes; the evidence for measures of anxiety in students learning how to perform intimate examinations; how well issues of sexuality are addressed in the literature; any reported negative effects of involvement in teaching on the patients, and suggestions for practical strategies for involving patients in the teaching of intimate examination skills. RESULTS: A total of 65 articles were included in the review. Involving patients in teaching intimate examination skills offers advantages over traditional methods of teaching. Objective evidence for the effectiveness of this method is demonstrated through improved clinical performance, reduced anxiety and positive evaluation of programmes. Practical strategies for implementing such programmes are also reported. CONCLUSIONS: There is evidence of a short-term positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still limited. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed.

What educators and students really think about using patients as teachers in medical education: a qualitative study.

OBJECTIVES: Patients play an integral part in medical education, either as passive, clinical exemplars or as more active facilitators in the development of skills. In theory, the patient-teacher may enhance the student learning experience by creating an environment similar to that of the medical workplace and encouraging the process of becoming a professional. Although many medical schools have integrated patient-teachers within their curricula, there is little evidence of how those involved in providing or receiving medical education view patient-teachers' contributions to their education. This study investigates the views and experiences of medical tutors and students of involving patients in undergraduate curricula. METHODS: We conducted a cross-sectional survey employing qualitative research methods. Semi-structured focus group interviews were used to elicit participants' views and experiences of patient involvement in medical education. The transcripts were content-analysed using a coding framework. RESULTS: A total of 46 participants consisting of medical educators and medical students took part in nine focus groups. Four themes emerged: the role of the patient in learning and teaching; the impact of the patient-teacher; the impact of being the storyteller, and mechanisms to explain the patient-teacher role in medical training. CONCLUSIONS: There is support for patient involvement in teaching. The logistics involved in supporting programmes of patient involvement and the need to link the teaching to overall course objectives should be addressed.

Strategies and interventions for the involvement of real patients in medical education: a systematic review.

OBJECTIVES: There is increasing emphasis on encouraging more active involvement of patients in medical education. This is based on the recognition of patients as 'experts' in their own medical conditions and may help to enhance student experiences of real-world medicine. This systematic review provides a summary of evidence for the role and effectiveness of real patient involvement in medical education. METHODS: MEDLINE, EMBASE, ERIC, PsychINFO, Sociological Abstracts and CINAHL were searched from the start of the databases to July 2007. Three key journals and reference lists of existing reviews were also searched. Articles published in English and reporting primary empirical research on the involvement of real patients in medical education were included. The synthesis of findings is integrated by narrative structured in such a way to address the research questions. RESULTS: A total of 47 articles were included in the review. The majority of studies reported patients in the role of teachers only; others described patient involvement in assessment or curriculum development or in combined roles. Patient involvement was recommended in order to bring the patient voice into education. There were several examples of how to recruit and train patients to perform an educational role. The effectiveness of patient involvement was measured by evaluation studies and reported improvements in skills. CONCLUSIONS: There was limited evidence of the long-term effectiveness of patient involvement and issues of ethics, psychological impact and influence on education policy were poorly explored. Future studies should address these issues and should explore the practicalities of sustaining such educational programmes within medical schools.

Using borderline methods to compare passing standards for OSCEs at graduation across three medical schools.

CONTEXT: Medical schools in the UK set their own graduating examinations and pass marks. In a previous study we examined the equivalence of passing standards using the Angoff standard-setting method. To address the limitation this imposed on that work, we undertook further research using a standard-setting method specifically designed for objective structured clinical examinations (OSCEs). METHODS: Six OSCE stations were incorporated into the graduating examinations of 3 of the medical schools that took part in the previous study. The borderline group method (BGM) or borderline regression method (BRM) was used to derive the pass marks for all stations in the OSCE. We compared passing standards at the 3 schools. We also compared the results within the schools with their previously generated Angoff pass marks. RESULTS: The pass marks derived using the BGM or BRM were consistent across 2 of the 3 schools, whereas the third school generated pass marks which were (with a single exception) much lower. Within-school comparisons of pass marks revealed that in 2 schools the pass marks generally did not significantly differ using either method, but for 1 school the Angoff mark was consistently and significantly lower than the BRM. DISCUSSION: The pass marks set using the BGM or BRM were more consistent across 2 of the 3 medical schools than pass marks set using the Angoff method. However, 1 medical school set significantly different pass marks from the other 2 schools. Although this study is small, we conclude that passing standards at different medical schools cannot be guaranteed to be equivalent.

A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine.

OBJECTIVES: An essential aspect of medical education is to facilitate the development and assessment of appropriate attitudes towards professionalism in medicine. This systematic review provides a summary of evidence for measures that have been used to assess these attitudes and their psychometric rigour. It also describes interventions that have been found to be effective in changing such attitudes. METHODS: MEDLINE, EMBASE, ERIC, PsychINFO, Sociological Abstracts and CINAHL were searched from the respective start date of each database to May 2006. Three key journals and reference lists of existing reviews were also searched. Articles that were published in English and reported primary empirical research measuring medical students' attitudes towards medical professionalism were included. The findings are integrated in narrative structured in such a way as to address the research questions. RESULTS: A total of 97 articles were included in the review. Most measures of attitudes assessed attitudes towards attributes of professionalism such as ethical issues, the patient-doctor relationship and cultural issues. Fourteen studies measured attitudes towards professionalism as a whole and 44 studies reported both the reliability and validity of measures. No interventions reported a change in attitudes over time. CONCLUSIONS: There is little evidence of reported measures that are effective in assessing attitudes towards professionalism in medicine as a whole. Likewise, there is scant evidence of interventions that influence attitude change over a period of time. Future studies should take into account the need to measure more global attitudes rather than attitudes towards specific issues in professionalism and the need to track attitudes throughout the curriculum.

Standard setting for clinical competence at graduation from medical school: a comparison of passing scores across five medical schools.

While Objective Structured Clinical Examinations (OSCEs) have become widely used to assess clinical competence at the end of undergraduate medical courses, the method of setting the passing score varies greatly, and there is no agreed best methodology. While there is an assumption that the passing standard at graduation is the same at all medical schools, there is very little quantitative evidence in the field. In the United Kingdom, there is no national licensing examination; each medical school sets its own graduating assessment and successful completion by candidates leads to the licensed right to practice by the General Medical Council. Academics at five UK medical school were asked to set passing scores for six OSCE stations using the Angoff method, following a briefing session on this technique. The results were collated and analysed. The passing scores set for the each of the stations varied widely across the five medical schools. The implication for individual students at the different medical schools is that a student with the same level of competency may pass at one medical school but would fail at another even when the test is identical. Postulated reasons for this difference include different conceptions of the minimal level of competence acceptable for graduating students and the possible unsuitability of the Angoff method for performance based clinical tests.

Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus.

OBJECTIVE: To establish an expert consensus of best practice for rheumatologists performing musculoskeletal ultrasonography (MUS). METHODS: A panel of worldwide experts in MUS was identified by literature review, membership of teaching faculty, and peer recommendation. They were invited to take part in a 4-stage Delphi process employing 2 iterative rounds to establish a consensus of specific indications, anatomic areas, and knowledge and skills required by rheumatologists performing MUS. RESULTS: Experts in MUS were identified (n = 57; 37 radiologists, 20 rheumatologists). Successive rounds of this rigorous Delphi exercise enabled group consensus to be achieved in 30 of the proposed 37 categories comprising 8 of 13 indications (inflammatory arthritis, tendon pathology, effusion, bursitis, monitoring disease activity, monitoring disease progression, guided aspiration, and injection), 8 of 10 anatomic areas (hand, wrist, elbow, shoulder, hip, knee, ankle and heel, and forefoot), and 14 categories of knowledge and skills (physics, anatomy, pathology, equipment, clinical application and relevance, indications and limitations, artifact, machine function and operation, patient and probe position, planes and system of examination, image optimization, dynamic assessment, color Doppler, and power Doppler). CONCLUSION: We have produced the first expert-derived, interdisciplinary consensus of recommendations for rheumatologists performing MUS. This represents a significant advance that will not only direct future rheumatology MUS practice, but will facilitate informed educational development. This is an important step towards the introduction of a specific training curriculum and assessment process to ensure competent rheumatologist ultrasonographers.