Medical curriculum reform in North America, 1765 to the present: a cognitive science perspective.

Since 1765, five major curricular reform movements have catalyzed significant changes in North American medical education. This article describes each reform movement in terms of its underlying educational practices and principles, inherent instructional problems, and the innovations that were carried forward. When considering the motivating factors underlying these reform movements, a unifying theme gradually emerges: increasing interest in, attention to, and understanding of the knowledge-base structures and cognitive processes that characterize and distinguish medical experts and novices. Concurrent with this emerging theme is a growing realization that medical educators must call upon and utilize the literature, research methods, and theoretical perspectives of cognitive science if future curricular reform efforts are to move forward efficiently and effectively. The authors hope that the discussion and perspective offered herein will broaden, stimulate, and challenge educators as they strive to create the reform movements that will define 21st-century medical education.

Effects of tutors with case expertise on problem-based learning issues.

At the University of Calgary Faculty of Medicine in 1991, the authors sought to determine the effects of tutors' levels of content expertise on learning issues generated within problem-based learning (PBL) tutorials. For an integrative course taken prior to clinical clerkships, the 70 students in the class of 1992 divided into ten small groups, which were facilitated alternately by content experts and non-experts. The authors found that--across 35 simulated-patient case encounters (24 with non-experts and 11 with experts)--when the groups had tutors with expertise in the clinical cases studied, the groups generated approximately twice as many learning issues per case, and these issues were approximately three times more congruent with the case objectives. In addition, when the groups had expert tutors they spent approximately twice as much time per case in overcoming identified learning deficiencies. The authors conclude that it is important for tutors (1) to be well informed about cases and case objectives and (2) to be well versed in the PBL tutoring process.

Development and evaluation of a Research Project Program for medical students at the University of Calgary Faculty of Medicine.

This essay outlines the development and evaluation of the Research Project Program (RPP) ten years after its introduction into the medical curriculum at the University of Calgary. The RPP consists of two mandatory for-credit courses. Students have the option of conducting either two smaller independent research projects or one larger project over the two years. At the end of the second-year course the students complete an evaluation of the RPP in which they are asked to assess and comment upon various aspects of the program. The authors compared data available from years one (the class of 1990) and ten (the class of 2000) and found significant differences between the two classes' approaches to the RPP. Most of the class of 2000 (89%) carried out two-year independent in-depth research projects spanning a wide range of topics. Half of these projects involved individual collection and analyses of data using experimental methods; this represented a 2.25-fold increase over the first year of the program. In the class of 2000, 44% of students presented their results at a newly implemented research symposium; an additional 22% of students presented their results at local, national, or international meetings. Further, 59% of the class of 2000 had either submitted or were planning to submit their research for peer-reviewed publication. In contrast, none of the students of the class of 1990 formally presented their research, and only 11% planned to submit their research findings for publication. The RPP has evolved in the ten years since its implementation, but the authors believe the program continues to foster independent learning and analytic and problem-solving skills.

Cuing effect of "all of the above" on the reliability and validity of multiple-choice test items.

It is generally acknowledged that alternatives such as none of the above and all of the above should be used sparingly in multiple-choice (MC) items. But the effect that all of the above has on the reliability and validity of an MC item is unclear. This study compared the results of a single-response (SRa) item format that included all of the above as the correct response to a multiple-response (MR) item format that required examinees to select all of the available alternatives for a correct response. A crossover design was used to compare the effect of formats on student performance while item content, scoring method, and student ability levels remained constant. Results indicated that the SRa format greatly distorted examinee performance by elevating their scores because examinees who recognized two or more alternatives as being correct were cued to select all of the above. In addition, the SRa format significantly reduced the reliability and concurrent validity of examinee scores. In summary, the MR format was found to be superior. Based upon new empirical evidence, this study recommends that whenever an educator wishes to evaluate student understanding of an issue that has multiple facts, the SRa format should be avoided and the MR format should be used instead.

Relationship between Myers-Briggs psychological traits and use of course objectives in anatomy and physiology.

The results from the Myers-Briggs Type Indicator (MBTI), which identified preferred psychological traits for 131 nursing students, were compared to their usage levels of course objectives in an undergraduate course in anatomy and physiology. The three usage levels (user, occasional user, and nonuser) were also compared to exam scores in the course, overall grade point averages (GPA) in first-year nursing, and the various psychological traits measured by the MBTI. A multivariate analysis of variance (MANOVA) indicated that users of objectives achieved significantly higher exam scores and maintained a higher GPA than occasional and nonusers. The MANOVA also indicated that users of course objectives preferred a sensing judging modality, whereas nonusers preferred an intuiting perceiving style to guide their studying and learning.

Relationship between Myers-Briggs Type Indicator and Gregorc Style Delineator.

The relationship between the Myers-briggs Type Indicator and Gregorc Style Delineator, and achievement was examined by administering these instruments to 259 first-year nursing students enrolled in an introductory human anatomy and physiology course. A principal component factor analysis using a varimax rotation of the scores from the two psychometric instruments, achievement examinations and an over-all grade point average indicated that each learning style from the Gregorc Style Delineator corresponds to certain traits on the Myers-Briggs Type Indicator. An individual who had a preference for the learning style of Concrete Sequential tended to have the traits of sensing and judging on the Myers-Briggs Type Indicator, while an individual who used the learning style of Concrete Random tended to have the traits of intuition and perceiving on the Myers-Briggs Type Indicator. One who had a preference for the learning style of Abstract Sequential tended to use the trait of thinking while another who used the learning style of Abstract Random tended to have the trait of feeling. The factor analysis also indicates no relationship of any scores of the traits on the Myers-Briggs Type Indicator or learning styles of the Gregorc Style Delineator with the examination scores achieved in the human anatomy and physiology course or to the students' over-all grade point average. However, factor analysis indicates that the Myers-Briggs Type Indicator traits of Judging vs Perceiving collapsed into the Sensing vs Intuition scale, and that the Gregorc Style Delineator consists of two bipolar scales that are different from those proposed by Gregorc.

Early introduction to medical problem-solving.

This is a descriptive report of a course unit designed to introduce concepts of medical problem-solving during the first month of an undergraduate MD curriculum. The unit is also used to provide an introduction to the dynamics of cooperative small group learning. The value of the unit was endorsed by the subjective opinions of faculty tutors and students, who recognized the relevance of the unit to the clinical practice of doctors. An end-of-course examination demonstrated that some novice medical problem-solvers have difficulty with recursive hypothesis testing and tend to use linear strategies. This type of learning experience has the potential to identify students who may have subsequent difficulty in clinical reasoning tasks in the curriculum. Medical problem-solving itself is the primary focus of problem-based learning in the unit. Experience with this unit suggests that concepts of medical problem-solving can be introduced into the curriculum at a very early stage, without a prerequisite for substantial knowledge of medical sciences.

Introducing first-year medical students to early diagnostic hypotheses.

The early formation of hypotheses is recognized as an important part of a clinical diagnosis (clinical problem-solving). This paper describes a method of instruction in gynecology for first-year medical students which encouraged the formulation of early diagnostic hypotheses. In paper and pencil case simulations designed for independent learning, students were provided with a set of clinical clues that helped them make broad general diagnostic hypotheses rather than the narrow hypotheses typical of beginning students. A description of the method of evaluating the student's ability to form diagnostic hypotheses, the results of evaluations, and the students' perceptions of the course are included in this report.

The quality of a simulation examination using a high-fidelity child manikin.

PURPOSE: Developing quality examinations that measure physicians' clinical performance in simulations is difficult. The goal of this study was to develop a quality simulation examination using a high-fidelity child manikin in evaluating paediatric residents' competence about managing critical cases in a simulated emergency room. Quality was determined by evidence of the reliability, validity and feasibility of the examination. In addition, the participants' responses regarding its realism, effectiveness and value are presented. METHOD: Scenario scripts and rating instruments were carefully developed in this study. Experts were used to validate the case scenarios and provide evidence of construct validity. Eighteen paediatric residents, 'working' as pairs, participated in a manikin-based simulation pre-test, a training session and a post-test. Three independent raters rated the participants' performance on task-specific technical skills, medications used and behaviours displayed. At the end of the simulation, the participants completed an evaluation questionnaire. RESULTS: The manikin-based simulation examination was found to be a realistic, valid and reliable tool. Validity (i.e. face, content and construct) of the test instrument was evident. The level of inter-rater concordance of participants' clinical performance was good to excellent. The item analysis showed good to excellent internal consistency on all the performance scores except the post-test technical score. CONCLUSIONS: With a carefully designed rating instrument and simulation operation, the manikin-based simulation examination was shown to be reliable and valid. However, a further refinement of the test instrument will be required for higher stake examinations.

The cutting edge: surgical education for medical students and a patient care system.

This paper describes computer-assisted instruction designed for medical students on their clinical surgery rotation. Patient care systems continue to evolve; incentives for physician participation should include educational benefits and clinical practice guidelines. Sometimes overlooked in the rush to develop expert systems are medical students, who do not have the depth of knowledge inherent in decision support. Foothills Hospital in Calgary, Canada, uses the TDS HC4000 patient care system, where physicians and medical students enter their orders directly on the terminals. The Surgical Patient Care Program was developed to help students learn the basics of peri-operative patient management. The Program runs on the HC4000 and consists of a collection of order sets with appended educational information to guide students in their automated order selection. Unlike other instructional programs, which use fictitious patients, students enter real orders on real patients. Tracking of usage indicates that the Program is popular with students, who each access it an average of 20 times per week. An ongoing study will determine any educational benefit by measuring student performance at Foothills Hospital against a control group at another hospital, which does not have a computerized patient care system.

Diagnostic reasoning strategies and diagnostic success.

PURPOSE: Cognitive psychology research supports the notion that experts use mental frameworks or "schemes", both to organize knowledge in memory and to solve clinical problems. The central purpose of this study was to determine the relationship between problem-solving strategies and the likelihood of diagnostic success. METHODS: Think-aloud protocols were collected to determine the diagnostic reasoning used by experts and non-experts when attempting to diagnose clinical presentations in gastroenterology. RESULTS: Using logistic regression analysis, the study found that there is a relationship between diagnostic reasoning strategy and the likelihood of diagnostic success. Compared to hypothetico-deductive reasoning, the odds of diagnostic success were significantly greater when subjects used the diagnostic strategies of pattern recognition and scheme-inductive reasoning. Two other factors emerged as independent determinants of diagnostic success: expertise and clinical presentation. Not surprisingly, experts outperformed novices, while the content area of the clinical cases in each of the four clinical presentations demonstrated varying degrees of difficulty and thus diagnostic success. CONCLUSIONS: These findings have significant implications for medical educators. It supports the introduction of "schemes" as a means of enhancing memory organization and improving diagnostic success.

Gregorc learning styles and achievement in anatomy and physiology.

Results from the Gregorc Style Delineator (GSD), administered to 260 undergraduate nursing students, were compared with achievement scores in a human anatomy and physiology course. Factor analysis and VARIMAX rotation demonstrate that there is no relationship between any of the four learning styles allegedly identified by the GSD and achievement in anatomy and physiology. Factor analysis also shows that the GSD measures only a single bipolar scale of sequential vs. random ability rather than two bipolar scales comprising four learning styles, as suggested by Gregorc. These findings question the validity of the GSD and recommend discontinuing its use as an indicator of learning styles.

Using an objective structured clinical examination to evaluate competency in sport medicine.

This article discusses the development, format, administration and scoring of the objective structured clinical examination (OSCE) to evaluate competency in sport medicine. The credentials committee of the Canadian Academy of Sport Medicine has developed an examination to evaluate the competency of practicing physicians in the field of sport medicine. The examination is based on a sport medicine matrix that includes five areas: (a) clinical patient care, (b) team and event coverage, (c) medical/legal issues, (d) teaching and administration, and (e) research. The emphasis is on clinical patient care followed by team and event coverage, with the other three areas having a lesser degree of importance. The OSCE format consists of a number of stations or scenarios based on this matrix. The candidates are evaluated on a check list that reflects the emphasis of each station. A typical clinical patient care problem includes check list items related to the history, physical examination, investigations, diagnosis, and treatment. The candidates are also evaluated for their attitudes and techniques on each station. The examination includes volunteer examiners and patients both simulated and real. The candidates are evaluated through the use of checklists that are filled in by the examiners on optical scoring sheets. These are collated and analyzed to generate comparisons between candidates and to determine the psychometric properties of the overall examination. The examination has consistently scored reliability coefficients of 0.8 or greater. The 1993 examination demonstrated reliability coefficients of 0.89-0.97. Interrater reliability was also calculated, and these values ranged from 0.85 to 0.99. The examination also reflects both face and content validity.(ABSTRACT TRUNCATED AT 250 WORDS)

Myers-Briggs psychological type and achievement in anatomy and physiology.

Results from the Myers-Briggs Type Indicator (MBTI) for 259 nursing students were compared with their achievement on examinations in an undergraduate course in anatomy and physiology. Factor analysis demonstrated that no relationship existed between any of the eight individual personality traits purported to be measured by MBTI (i.e., E, Extrovert; I, Introvert; S, Sensing; N, Intuition; T, Thinking; F, Feeling; J, Judging; P, Perceiving) and examination scores in this course. The analysis also showed that the bipolar scales S vs. N and J vs. P collapsed into a single bipolar scale (S/J vs. N/P). This means that the MBTI is only capable of measuring three bipolar scales of personality traits instead of four scales as currently claimed. Contrary to other findings, results from an analysis of variance revealed no meaningful relationship between course achievement and psychological types.