How well do UK assistantships equip medical students for graduate practice? Think EPAs.

The goal of better medical student preparation for clinical practice drives curricular initiatives worldwide. Learning theory underpins Entrustable Professional Activities (EPAs) as a means of safe transition to independent practice. Regulators mandate senior assistantships to improve practice readiness. It is important to know whether meaningful EPAs occur in assistantships, and with what impact. Final year students at one UK medical school kept learning logs and audio-diaries for six one-week periods during a year-long assistantship. Further data were also obtained through interviewing participants when students and after three months as junior doctors. This was combined with data from new doctors from 17 other UK schools. Realist methods explored what worked for whom and why. 32 medical students and 70 junior doctors participated. All assistantship students reported engaging with EPAs but gaps in the types of EPAs undertaken exist, with level of entrustment and frequency of access depending on the context. Engagement is enhanced by integration into the team and shared understanding of what constitutes legitimate activities. Improving the shared understanding between student and supervisor of what constitutes important assistantship activity may result in an increase in the amount and/or quality of EPAs achieved.

Training healthcare professionals to be ready for practice in an era of social distancing: a realist evaluation.

BACKGROUND: Programme changes due to the COVID-19 pandemic have impacted variably on preparation for practice of healthcare professional students. Explanations for such variability need exploration. The aim of our study was to understand what clinical learning, whilst under socially distanced restrictions, worked and why (or why not). METHODS: We conducted a realist evaluation of the undergraduate healthcare programmes at one UK university in 2020-21. Initial programme theories to be tested in this study were derived from discussions with programme leads about the changes they implemented due to the pandemic. Study participants were students and teaching faculty. Online interview transcripts were coded, identifying why interventions had worked or not. This resulted in a set of 'context-mechanism-outcome' (CMO) statements about each intervention. The initial programme theories were refined as a result. RESULTS AND DISCUSSION: 29 students and 22 faculty members participated. 18 CMO configurations were identified relating to clinical skills learning and 25 relating to clinical placements. Clinical skills learning was successful whether in person, remote or hybrid if it followed the steps of: demonstration-explanation-mental rehearsal-attempt with feedback. Where it didn't work there was usually a lack of observation and corrective feedback. Placements were generally highly valued despite some deficiencies in student experience. Being useful on placements was felt to be good preparation for practice. If student numbers are to expand, findings about what works in distance learning of clinical skills and the value of various modes of induction to clinical workplace activity may also be relevant post-pandemic.

How do medical students' experiences inform their opinions of general practice and its potential as a future career choice?

Recruitment of general practitioners (GPs) in the UK has been suboptimal. There is a wealth of literature exploring recruitment into general practice and opinions of general practice, set in many contexts. This paper aims to synthesise all the elements and extract mechanisms to explain what works, for whom in what circumstances, to create a comprehensive understanding and highlight potential target areas for improvement to improve understanding and fuel interest in general practice careers. A realist review of literature and contemporary data was conducted in line with RAMESES standards. Analysis and synthesis were aided by NVivo. An initial program theory was developed following discussion with expert informers. Sections of text from included literature relating to program theory were extracted and synthesised into a final program theory using a realist logic of analysis in which recurring Context-Mechanism-Outcome configurations (CMOCs) were identified. Searches identified 27 relevant documents. Twenty recurring CMOCs were extracted, explaining how student perceptions of General Practice were influenced by placement experiences, comments from hospital doctors, medical school faculty, peers, GPs, student perceptions of lifestyle and the media. The GP placement environment plays an important role in the formation of opinions about the speciality. The impact of social influence varies depending on the student's desire to belong to a reference group and their level of self-monitoring behaviour. The 'GP lifestyle' was judged to be compatible with many students' needs. This realist review provides recommendations on how curricula can adapt to provide an accurate insight into general practice.

Can learning from workplace feedback be enhanced by reflective writing? A realist evaluation in UK undergraduate medical education.

Introduction: Doctors and medical students in the UK are currently required to provide evidence of learning by reflective writing on (among other things) feedback from colleagues. Although the theoretical value of reflecting-on-action is clear, research is still needed to know how to realise the potential of written reflection in medical education. This study arose out of efforts to improve medical student engagement with a reflective writing exercise. We used realist methodology to explain the disinclination of the majority to do written reflection on workplace feedback, and the benefits to the minority.Method: Realist evaluation is a suitable approach to researching complex interventions which have worked for some and not for others. Focus groups were held over a three-year period with year 3 and 4 students. Focus group transcripts were coded for context-mechanism-outcome configurations (the realist approach to analysing data) explaining students' choice not to write a reflection, to write a 'tick-box' reflection or to write for learning. A sub-set of eight students' reflections were also analysed to ascertain evidence of learning through reflection.Results and discussion: 27 students participated in 4 focus groups. Three summary theories emerged showing the importance of context. Firstly, written reflection is effortful and benefits those who invest in it for intrinsic reasons in situations when they need to think more deeply about a learning event. Secondly, following a reflective feedback discussion writing a reflection may add little because the learning has already taken place. Thirdly, external motivation tends to result in writing a 'tick-box' reflection.

Clinical assessors' working conceptualisations of undergraduate consultation skills: a framework analysis of how assessors make expert judgements in practice.

Undergraduate clinical assessors make expert, multifaceted judgements of consultation skills in concert with medical school OSCE grading rubrics. Assessors are not cognitive machines: their judgements are made in the light of prior experience and social interactions with students. It is important to understand assessors' working conceptualisations of consultation skills and whether they could be used to develop assessment tools for undergraduate assessment. To identify any working conceptualisations that assessors use while assessing undergraduate medical students' consultation skills and develop assessment tools based on assessors' working conceptualisations and natural language for undergraduate consultation skills. In semi-structured interviews, 12 experienced assessors from a UK medical school populated a blank assessment scale with personally meaningful descriptors while describing how they made judgements of students' consultation skills (at exit standard). A two-step iterative thematic framework analysis was performed drawing on constructionism and interactionism. Five domains were found within working conceptualisations of consultation skills: Application of knowledge; Manner with patients; Getting it done; Safety; and Overall impression. Three mechanisms of judgement about student behaviour were identified: observations, inferences and feelings. Assessment tools drawing on participants' conceptualisations and natural language were generated, including 'grade descriptors' for common conceptualisations in each domain by mechanism of judgement and matched to grading rubrics of Fail, Borderline, Pass, Very good. Utilising working conceptualisations to develop assessment tools is feasible and potentially useful. Work is needed to test impact on assessment quality.

'What do we do, doctor?' Transitions of identity and responsibility: a narrative analysis.

Transitioning from student to doctor is notoriously challenging. Newly qualified doctors feel required to make decisions before owning their new identity. It is essential to understand how responsibility relates to identity formation to improve transitions for doctors and patients. This multiphase ethnographic study explores realities of transition through anticipatory, lived and reflective stages. We utilised Labov's narrative framework (Labov in J Narrat Life Hist 7(1-4):395-415, 1997) to conduct in-depth analysis of complex relationships between changes in responsibility and development of professional identity. Our objective was to understand how these concepts interact. Newly qualified doctors acclimatise to their role requirements through participatory experience, perceived as a series of challenges, told as stories of adventure or quest. Rules of interaction within clinical teams were complex, context dependent and rarely explicit. Students, newly qualified and supervising doctors felt tensions around whether responsibility should be grasped or conferred. Perceived clinical necessity was a common determinant of responsibility rather than planned learning. Identity formation was chronologically mismatched to accepting responsibility. We provide a rich illumination of the complex relationship between responsibility and identity pre, during, and post-transition to qualified doctor: the two are inherently intertwined, each generating the other through successful actions in practice. This suggests successful transition requires a supported period of identity reconciliation during which responsibility may feel burdensome. During this, there is a fine line between too much and too little responsibility: seemingly innocuous assumptions can have a significant impact. More effort is needed to facilitate behaviours that delegate authority to the transitioning learner whilst maintaining true oversight.

Understanding and developing procedures for video-based assessment in medical education.

INTRODUCTION: Novel uses of video aim to enhance assessment in health-professionals education. Whilst these uses presume equivalence between video and live scoring, some research suggests that poorly understood variations could challenge validity. We aimed to understand examiners' and students' interaction with video whilst developing procedures to promote its optimal use. METHODS: Using design-based research we developed theory and procedures for video use in assessment, iteratively adapting conditions across simulated OSCE stations. We explored examiners' and students' perceptions using think-aloud, interviews and focus group. Data were analysed using constructivist grounded-theory methods. RESULTS: Video-based assessment produced detachment and reduced volitional control for examiners. Examiners ability to make valid video-based judgements was mediated by the interaction of station content and specifically selected filming parameters. Examiners displayed several judgemental tendencies which helped them manage videos' limitations but could also bias judgements in some circumstances. Students rarely found carefully-placed cameras intrusive and considered filming acceptable if adequately justified. DISCUSSION: Successful use of video-based assessment relies on balancing the need to ensure station-specific information adequacy; avoiding disruptive intrusion; and the degree of justification provided by video's educational purpose. Video has the potential to enhance assessment validity and students' learning when an appropriate balance is achieved.

Qualitative research using realist evaluation to explain preparedness for doctors' memorable 'firsts'.

CONTEXT: Doctors must be competent from their first day of practice if patients are to be safe. Medical students and new doctors are acutely aware of this, but describe being variably prepared. OBJECTIVES: This study aimed to identify causal chains of the contextual factors and mechanisms that lead to a trainee being capable (or not) of completing tasks for the first time. METHODS: We studied three stages of transition: anticipation; lived experience, and post hoc reflection. In the anticipation stage, medical students kept logbooks and audio diaries and were interviewed. Consenting participants were followed into their first jobs as doctors, during which they made audio diaries to capture the lived experiences of transition. Reflection was captured using interviews and focus groups with other postgraduate trainee doctors. All materials were transcribed and references to first experiences ('firsts') were analysed through the lens of realist evaluation. RESULTS: A total of 32 medical students participated. Eleven participants were followed through the transition to the role of doctor. In addition, 70 postgraduate trainee doctors from three local hospitals who were graduates of 17 UK medical schools participated in 10 focus groups. We identified three categories of firsts (outcomes): firsts that were anticipated and deliberately prepared for in medical school; firsts for which total prior preparedness is not possible as a result of the step change in responsibility between the student and doctor identities, and firsts that represented experiences of failure. Helpful interventions in preparation (context) were opportunities for rehearsal and being given responsibility as a student in the clinical team. Building self-efficacy for tasks was an important mechanism. During transition, the key contextual factor was the provision of appropriate support from colleagues. CONCLUSIONS: Transition is a step change in responsibility for which total preparedness is not achievable. This transition is experienced as a rite of passage when the newly qualified doctor first makes decisions alone. This study extends the existing literature by explaining the mechanisms involved in preparedness for firsts.

Grades in formative workplace-based assessment: a study of what works for whom and why.

CONTEXT: Grades are commonly used in formative workplace-based assessment (WBA) in medical education and training, but may draw attention away from feedback about the task. A dilemma arises because the self-regulatory focus of a trainee must include self-awareness relative to agreed standards, which implies grading. OBJECTIVES: In this study we aimed to understand the meaning which medical students construct from WBA feedback with and without grades, and what influences this. METHODS: Year 3 students were invited to take part in a randomised crossover study in which each student served as his or her own control. Each student undertook one WBA with and one without grades, and then chose whether or not to be given grades in a third WBA. These preferences were explored in semi-structured interviews. A realist approach to analysis was used to gain understanding of student preferences and the impact of feedback with and without grades. RESULTS: Of 83 students who were given feedback with and without grades, 65 (78%) then chose to have feedback with grades and 18 (22%) without grades in their third WBA. A total of 24 students were interviewed. Students described how grades locate their performance and calibrate their self-assessment. For some, low grades focused attention and effort. Satisfactory and high grades enhanced self-efficacy. CONCLUSIONS: Grades are concrete, powerful and blunt, can be harmful and need to be explained to help students create helpful meaning from them. Low grades risk reducing self-efficacy in some and may encourage others to focus on proving their ability rather than on improvement. A metaphor of the semi-permeable membrane is introduced to elucidate how students reduced potential negative effects and enhanced the positive effects of feedback with grades by selective filtering and pumping. This study illuminates the complexity of the processing of feedback by its recipients, and informs the use of grading in the provision of more effective, tailored feedback.

Development and face validation of strategies for improving consultation skills.

While formative workplace based assessment can improve learners' skills, it often does not because the procedures used do not facilitate feedback which is sufficiently specific to scaffold improvement. Provision of pre-formulated strategies to address predicted learning needs has potential to improve the quality and automate the provision of written feedback. To systematically develop, validate and maximise the utility of a comprehensive list of strategies for improvement of consultation skills through a process involving both medical students and their clinical primary and secondary care tutors. Modified Delphi study with tutors, modified nominal group study with students with moderation of outputs by consensus round table discussion by the authors. 35 hospital and 21 GP tutors participated in the Delphi study and contributed 153 new or modified strategies. After review of these and the 205 original strategies, 265 strategies entered the nominal group study to which 46 year four and five students contributed, resulting in the final list of 249 validated strategies. We have developed a valid and comprehensive set of strategies which are considered useful by medical students. This list can be immediately applied by any school which uses the Calgary Cambridge Framework to inform the content of formative feedback on consultation skills. We consider that the list could also be mapped to alternative skills frameworks and so be utilised by schools which do not use the Calgary Cambridge Framework.

How do medical schools influence their students' career choices? A realist evaluation.

INTRODUCTION: The career choices of medical graduates vary widely between medical schools in the UK and elsewhere and are generally not well matched with societal needs. Research has found that experiences in medical school including formal, informal and hidden curricula are important influences. We conducted a realist evaluation of how and why these various social conditions in medical school influence career thinking. METHODS: We interviewed junior doctors at the point of applying for speciality training. We selected purposively for a range of career choices. Participants were asked to describe points during their medical training when they had considered career options and how their thinking had been influenced by their context. Interview transcripts were coded for context-mechanism-outcome (CMO) configurations to test initial theories of how career decisions are made. RESULTS: A total of 26 junior doctors from 12 UK medical schools participated. We found 14 recurring CMO configurations in the data which explained influences on career choice occurring during medical school. DISCUSSION: Our initial theories about career decision-making were refined as follows: It involves a process of testing for fit of potential careers. This process is asymmetric with multiple experiences needed before deciding a career fits ('easing in') but sometimes only a single negative experience needed for a choice to be ruled out. Developing a preference for a speciality aligns with Person-Environment-Fit decision theories. Ruling out a potential career can however be a less thought-through process than rationality-based decision theories would suggest. Testing for fit is facilitated by longer and more authentic undergraduate placements, allocation of and successful completion of tasks, being treated as part of the team and enthusiastic role models. Informal career guidance is more influential than formal. We suggest some implications for medical school programmes.

Exploring practice and perspectives on shared decision-making about osteoporosis medicines in Fracture Liaison Services: the iFraP development qualitative study.

Interviews and focus groups with patients, FLS clinicians, and GPs identified challenges relating to clinical and shared decision-making about bone health and osteoporosis medicines. Findings will inform the development of the multicomponent iFraP intervention to address identified training needs and barriers to implementation to facilitate SDM about osteoporosis medicines. PURPOSE: The iFraP (improving uptake of Fracture Prevention treatments) study aimed to develop a multicomponent intervention, including an osteoporosis decision support tool (DST), to support shared decision-making (SDM) about osteoporosis medicines. To inform iFraP intervention development, this qualitative study explored current practice in relation to communication about bone health and osteoporosis medicines, anticipated barriers to, and facilitators of, an osteoporosis DST, and perceived training needs. METHODS: Patients attending an FLS consultation (n = 8), FLS clinicians (n = 9), and general practitioners (GPs; n = 7) were purposively sampled to participate in a focus group and/or telephone interview. Data were transcribed, inductively coded, and then mapped to the Theoretical Domains Framework (TDF) as a deductive framework to systematically identify possible barriers to, and facilitators of, implementing a DST. RESULTS: Inductive codes were deductively mapped to 12 TDF domains. FLS clinicians were perceived to have specialist expertise (knowledge). However, clinicians described aspects of clinical decision-making and risk communication as difficult (cognitive skills). Patients reflected on decisional uncertainty about medicines (decision processes). Discussions about current practice and the proposed DST indicated opportunities to facilitate SDM, if identified training needs are met. Potential individual and system-level barriers to implementation were identified, such as differences in FLS configuration and a move to remote consulting (environmental context and resources). CONCLUSIONS: Understanding of current practice revealed unmet training needs, indicating that using a DST in isolation would be unlikely to produce a sustained shift to SDM. Findings will shape iFraP intervention development to address unmet needs.

A person-centred consultation intervention to improve shared decision-making about, and uptake of, osteoporosis medicines (iFraP): a pragmatic, parallel-group, individual randomised controlled trial protocol.

Background: Good quality shared decision-making (SDM) conversations involve people with, or at risk of osteoporosis and clinicians collaborating to decide, where appropriate, which evidence-based medicines best fit the person's life, beliefs, and values. We developed the improving uptake of Fracture Prevention drug treatments (iFraP) intervention comprising a computerised Decision Support Tool (DST), clinician training package and information resources, for use in UK Fracture Liaison Service consultations.Two primary objectives to determine (1) the effect of the iFraP intervention on patient-reported ease in decision-making about osteoporosis medicines, and (2) cost-effectiveness of iFraP intervention compared to usual NHS care. Secondary objectives are to determine the iFraP intervention effect on patient reported outcome and experience measures, clinical effectiveness (osteoporosis medicine adherence), and to explore intervention acceptability, mechanisms, and processes underlying observed effects, and intervention implementation. Methods: The iFraP trial is a pragmatic, parallel-group, individual randomised controlled trial in patients referred to a Fracture Liaison Service, with nested mixed methods process evaluation and health economic analysis. Participants aged ≥50 years (n=380) are randomised (1:1 ratio) to one of two arms: (1) iFraP intervention (iFraP-i) or (2) comparator usual NHS care (iFraP-u) and are followed up at 2-weeks and 3-months. The primary outcome is ease of decision-making assessed 2 weeks after the consultation using the Decisional Conflict Scale (DCS). The primary objectives will be addressed by comparing the mean DCS score in each trial arm (using analysis of covariance) for patients given an osteoporosis medicine recommendation, alongside a within-trial cost-effectiveness and value of information (VoI) analysis. Process evaluation data collection includes consultation recordings, semi-structured interviews, and DST analytics. Discussion: The iFraP trial will answer important questions about the effectiveness of the new 'iFraP' osteoporosis DST, coupled with clinician training, on SDM and informed initiation of osteoporosis medicines. Trial registration ISRCTN: 10606407, 21/11/2022 https://doi.org/10.1186/ISRCTN10606407.

Background: For people with osteoporosis, broken bones (called 'fragility fractures') can occur from low or no trauma and cause significant disability. Medicines can strengthen bone and lower the chance of fragility fractures. However, many people who experience a fragility fracture do not start or continue taking osteoporosis medicines. People commonly choose not to take osteoporosis medicines because they are unsure what medicines are for, confused about fracture 'risk' and/or worried about side-effects. To address this, we developed the 'iFraP intervention': 1. The iFraP 'decision-support tool': to support patients and healthcare professionals talk together to make decisions about medicines2. iFraP training for healthcare professionals to:a. use the tool in appointments with patientsb. give understandable, clear and consistent information c. listen to and address patient concerns This trial investigates whether the iFraP intervention makes decision-making about osteoporosis medicines easier, and whether it is cost-effective, acceptable and practical to deliver. Methods: 380 patients will take part who will be 50 years and older and referred to a fracture prevention service, because they have broken a bone. Patients taking part will be allocated to receive either a usual NHS appointment or an appointment using the iFraP intervention. Patients will complete a questionnaire before their appointment, and 2 weeks and 3 months afterwards. Some patients will be asked if they consent to have their appointment recorded and/or be interviewed, to understand how the decision-support tool is being used, and patient's views of the iFraP intervention. Outputs: If successful, the iFraP intervention will benefit patients and the NHS by helping patients make decisions about osteoporosis medicine. If the iFraP intervention increases the number of people with osteoporosis that start and continue taking osteoporosis medicines, iFraP will lower the number of future fractures, and reduce the negative outcomes that result from fractures (e.g. significant disability).

Minding the gap between communication skills simulation and authentic experience.

CONTEXT: Concurrent exposure to simulated and authentic experiences during undergraduate medical education is increasing. The impact of gaps or differences between contemporaneous experiences has not been adequately considered. We address two questions. How do new undergraduate medical students understand contemporaneous interactions with simulated and authentic patients? How and why do student perceptions of differences between simulated and authentic patient interactions shape their learning? METHODS: We conducted an interpretative thematic secondary analysis of research data comprising individual interviews (n = 23), focus groups (three groups, n = 16), and discussion groups (four groups, n = 26) with participants drawn from two different year cohorts of Year 1 medical students. These methods generated data from 48 different participants, of whom 17 provided longitudinal data. In addition, data from routinely collected written evaluations of three whole Year 1 cohorts (response rates ≥ 88%, n = 378) were incorporated into our secondary analysis dataset. The primary studies and our secondary analysis were conducted in a single UK medical school with an integrated curriculum. RESULTS: Our analysis identified that students generate knowledge and meaning from their simulated and authentic experiences relative to each other and that the resultant learning differs in quality according to meaning created by comparing and contrasting contemporaneous experiences. Three themes were identified that clarify how and why the contrasting of differences is an important process for learning outcomes. These are preparedness, responsibility for safety, and perceptions of a gap between theory and practice. CONCLUSIONS: We propose a conceptual framework generated by reframing common metaphors that refer to the concept of the gap to develop educational strategies that might maximise useful learning from perceived differences. Educators need to 'mind' gaps in collaboration with students if synergistic learning is to be constructed from contemporaneous exposure to simulated and authentic patient interactions. The strategies need to be tested in practice by teachers and learners for utility. Further research is needed to understand gaps in other contexts.

Twelve tips for peer teaching by a medical education student society.

University societies are student-led organisations which provide excellent opportunities for students to collaborate in a shared interest. Peer teaching is gaining recognition as an effective method of medical education. Peer teaching also provides student tutors with core educational skills and provides students with approachable peer mentors. This article offers practical guidance on organising, planning, executing and sustaining peer teaching via a medical education society at university and outlines the supporting literature.

Feasibility study of student telehealth interviews.

BACKGROUND: The COVID-19 pandemic has led to medical students being taught remote clinical communication modalities (telephone and video). Junior students have not generally been included in this and have had less patient contact than previously. This study aimed to examine the feasibility from the junior student viewpoint of conducting both modalities of patient telehealth interviews. METHODS: An electronic questionnaire was used to discover Year 1 student reasons for their preferred modality after they had conducted one telephone and one video interview in pairs with a patient volunteer. Student views on the challenge and benefits of each were also sought. FINDINGS: A total of 55 (32.7% of the cohort) responded, of whom 82% preferred video consultation, 75.6% of those stating being able to see their patient/partner was a key factor. About 5% preferred telephone interview, and 13% had no preference. Telephone interviews were perceived as the more challenging (40% versus 12.7%); however, challenge did not directly link with lack of comfort. There were some technical/connectivity issues with both modalities, and the telephone call system was more complex to set up. Turn-taking was more difficult by telephone without visual cues. DISCUSSION: This is the first direct comparison study in junior medical students of real patient interviews by video or telephone. Students embraced the challenge and, although preferring video and finding telephone more challenging, valued each as an educational experience. CONCLUSIONS: Telehealth interviews with patients for junior students are feasible, give needed patient exposure, practical insights into remote modalities and consolidate communication skills learnt in the classroom.

Some like it hot: medical student views on choosing the emotional level of a simulation.

OBJECTIVES: This study aimed to determine the impact of giving junior medical students control over the level of emotion expressed by a simulated patient (SP) in a teaching session designed to prepare students to handle emotions when interviewing real patients on placements. METHODS: Year 1 medical students at Keele University School of Medicine were allowed to set the degree of emotion to be displayed by the SP in their first 'emotional interview'. This innovation was evaluated by mixed methods in two consecutive academic years as part of an action research project, along with other developments in a new communications skills curriculum. Questionnaires were completed after the first and second iterations by students, tutors and SPs. Sixteen students also participated in evaluative focus group discussions at the end of Year 1. RESULTS: Most students found the 'emotion-setting switch' helpful, both when interviewing the SP and when observing. Student-interviewers were helped by the perception that they had control over the difficulty of the task. Student-observers found it helpful to see the different levels of emotion and to think about how they might empathise with patients. By contrast, some students found the 'control switch' unnecessary or even unhelpful. These students felt that challenge was good for them and preferred not to be given the option of reducing it. DISCUSSION: The emotional level control was a useful innovation for most students and may potentially be used in any first encounter with challenging simulation. We suggest that it addresses innate needs for competence and autonomy. The insights gained enable us to suggest ways of building the element of choice into such sessions. The disadvantages of choice highlighted by some students should be surmountable by tutor 'scaffolding' of the learning for both student-interviewers and student-observers.

Comparing the influence of 'describing findings to the examiner' or 'examining as in usual practice' on the students' performance and assessors' judgements during physical examination skills assessment.

This article was migrated. The article was marked as recommended. BACKGROUND: Within assessment of physical examination skills, two approaches are common: "Describing Findings" (students comment throughout); and examining as "Usual Practice" (students only report findings at the end). Despite numerous potential influences on both students' performances and assessors' judgements, no prior studies have investigated the influence of either approach on assessments. METHODS: Two group, randomised, crossover design. Within a 2-station simulated physical examination OSCE, we manipulated whether students "described findings" or examined as "usual practice", collecting 1/. performance scores; 2/. Students'/examiners' cognitive load ratings; ratings of the 3/. fluency and 4/. completeness of students' presentations and 5/. Students' task-finishing, comparing all 5 end-points across conditions. RESULTS: Neither students' performance scores nor examiners' cognitive load were influenced by experimental condition. Students reported higher cognitive load (7/9) when "describing findings" than "usual practice" (6/9, p=0.002), and were less likely to finish (4 vs 12, p=0.007). Presentation completeness was higher for "describing findings" (mean=2.40, (95CIs=2.05-2.74)) than "usual practice" (mean=1.92 (1.65-2.18),p=0.016), whilst fluency ratings showed a similar trend. CONCLUSIONS: The decision to "Describe Findings" or examine as "Usual Practice" does not appear neutral, potentially influencing students' efficiency, recall and (by inference) learning. Institutions should explicitly select one option based on assessment goals.

Medical students' perceptions of bedside teaching.

BACKGROUND: Bedside teaching is recognised as a valuable tool in medical education by both students and faculty members. Bedside teaching is frequently delivered by consultants; however, junior doctors are increasingly engaging in this form of clinical teaching, and their value in this respect is becoming more widely recognised. The aim of this study was to supplement work completed by previous authors who have begun to explore students' satisfaction with bedside teaching, and their perceptions of the relationship with the clinical teachers. Specifically, we aimed to identify how students perceive bedside teaching delivered by junior doctors compared with consultants. We aimed to identify how students perceived bedside teaching delivered by junior doctors compared with consultants METHODS: A questionnaire was distributed to all third-year medical students at Keele University via e-mail. Responses were submitted anonymously. RESULTS: Forty-six students responded (37.4%), 73.3 per cent of whom said that they felt more comfortable having bedside teaching delivered by junior doctors than by consultants. Consultants were perceived as more challenging by 60 per cent of respondents. Students appeared to value feedback on their performance, trust the validity of taught information, and to value the overall educational experience equally, regardless of the clinical grade of the teacher. DISCUSSION: Student preference does not equate to the value that they place on their bedside teaching. Junior doctors are perceived as being more in touch with students and the curriculum, whereas consultants are perceived as having higher expectations and as being both stricter and more knowledgeable. The clinical teacher's approachable manner and enthusiasm for teaching are more important than clinical grade, as is the ability to deliver well-structured constructive feedback.