Difference in demographics and motivation to study medicine with respect to medical students' channel of admission: A national study.

INTRODUCTION: Medical schools employ various tools to select suitable medical students (MS). This study investigated whether MS who were admitted through multiple mini-interviews (MMI) and MS who were admitted through Taiwan's Joint College Entrance Written Test (JCEWT) differed in their characteristics. METHODS AND SUBJECTS: First-year MS from seven medical schools completed a semi-structured questionnaire that inquired into their channel of admission (MMI or JCEWT), gender, location (metropolitan or rural), high school type (public or private), parents' socioeconomic status (SES), and motivations to study medicine. RESULTS: In total, 513 MS participated, 493 (96%) returned valid questionnaires, and 397 were enrolled in the study, (MMI group: 205 MS; JCEWT group: 192 MS). Irrespective of channel of admission, most MS came from metropolitan areas (80%-86%), belonged to high-SES families (73%-76%), and had mixed motivations (51%-96%). Female applicants, private school leavers, and those who were less motivated by the physician's SES were more likely to be selected through the MMI channel than the JCEWT channel. CONCLUSION: Irrespective of the channels of entry, MS had similar demographics and motivations for studying medicine. MS selected through MMI had different characteristics than those selected through a JCEWT.

[The Development and Application of Virtual Patient in Clinical Training: The New Horizon for Nursing Education].

Clinical problem-solving training that involves hands-on practice with patients is regarded as an important yet challenging aspect of medical education. A majority of schools around the world have suspended face-to-face classes because of the COVID-19 pandemic. Although remote digital classes represent a widely adopted alternative approach to education, the format of these classes is poorly suited to clinical learning and examination. With advances in virtual technology using natural language processing and multimedia, virtual patients bring vivid clinical encounters with records and feedback and are able to facilitate learning in the realm of clinical problem-solving. Virtual patients may be used to replace paper cases, human patients, and standardized patients in clinical education. The related applications include virtual problem-based learning in group training, clinical skill examination, and cloud-based virtual training. Integrating online meeting systems with virtual patient systems effectively overcomes the barriers of learning related to distance and isolation. The cloud model is especially important in the pandemic period, as this model allows clinical team work training to continue outside of actual hospital settings. In conclusion, technology-assisted simulation has innovated clinical training and assessment. The success of technology-enhanced education relies on its alignment with students' level of training and targeted learning objectives, especially when coupled with observation and feedback. The success of clinical education will guarantee the improvement of students' clinical competency.

Twelve tips for the construction of ethical dilemma case-based assessment.

Ethical dilemma case-based examination (ethics Script Concordance Test, eSCT) is a written examination that can be delivered to a large group of examinees for the purpose of measuring high-level thinking. As it accommodates for diverse responses from experts, ethics SCT allows partial credits. The framework of ethics SCT includes a vignette with an ethical dilemma and a leading question, which asks the examinee to "agree" or "disagree", plus the shifts of prior decision by adding new information. In this article, the following tips for constructing this type of examination are provided: use "true" dilemmas, select an appropriate ethical issue, target high-level cognitive tasks, list key components, keep a single central theme, device quality scoring system, be important and plausible, be clear, select quality experts, validate, know the limitation, and be familiar with test materials. The use of eSCT to measure ethical reasoning ability appears to be both viable and desirable.

Hospital-based school for children with chronic illness in Taiwan.

BACKGROUND/PURPOSE: To provide educational support and avoid unwanted damage that may impede learning for children with chronic illness, the learning environment should be friendly and safe. There is a need to establish schools inside hospitals, however, which may be neglected in a highly efficient health care system. A study was conducted to identify hospital-based schools for sick children in Taiwan, and to explore the barriers for implementation. METHODS: The data were collected by structured telephone interview and retrieval of hospital web information. The study targeted social workers and nurses in the pediatric wards of 29 hospitals, plus officials from the Education Bureau in Taiwan. The interviewers inquired about the availability of a formal educational program inside hospitals and the barriers (if any) in providing educational supports. RESULTS: Taiwan has only one hospital-based informal school and eight hospitals with rotating bedside teachers. Education inside hospitals occurs mostly through voluntary teaching in informal education models. Information about special educational resources has not been widely distributed to patients and health care providers. Professional personnel in Taiwan are not well aware of the needs to establish a hospital-based school. CONCLUSION: The educational needs of children with chronic illness can be easily neglected even in an industrialized country. The establishment of policy and the enrichment of professional education on advocacy are necessary to eliminate educational inequities and benefit sick children.

Power of the policy: how the announcement of high-stakes clinical examination altered OSCE implementation at institutional level.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) has been widely applied as a high-stakes examination for assessing physicians' clinical competency. In 1992, OSCE was first introduced in Taiwan, and the authorities announced that passing the OSCE would be a prerequisite for step-2 medical licensure examination in 2013. This study aimed to investigate the impacts of the announced national OSCE policy on implementation of OSCE at the institutional level. Further, the readiness and the recognition of barriers toward a high-stakes examination were explored. METHODS: In 2007 and 2010, the year before and after the announcement of high-stakes OSCE policy in 2008, respectively, questionnaires on the status of OSCE implementation were distributed to all hospitals with active OSCE programs in Taiwan. Information on OSCE facilities, equipment, station length, number of administrations per year, and the recognition of barriers to the success of implementing an OSCE were collected. The missing data were completed by telephone interviews. The OSCE format, administration, and facilities before and after the announcement of the nationwide OSCE policy were compared. RESULTS: The data were collected from 17 hospitals in 2007 and 21 in 2010. Comparing the OSCE formats between 2007 and 2010, the number of stations increased and the station length decreased. The designated space and the equipment for OSCE were also found to have been improved. As for the awareness of OSCE implementation barriers, the hospital representatives concerned mostly about the availability and quality of standardized patients in 2007, as well as space and facilities in 2010. CONCLUSIONS: The results of this study underscored an overall increase in the number of OSCE hospitals and changes in facilities and formats. While recruitment and training of standardized patients were the major concerns before the official disclosure of the policy, space and facilities became the focus of attention after the announcement. The study results highlighted the influence of government policy on different aspects of OSCE implementation in Taiwanese training institutes that showed high level of support as reflected in the improved hardware and the change in OSCE format to serve the summative purpose.

Predicting the demand of physician workforce: an international model based on "crowd behaviors".

BACKGROUND: Appropriateness of physician workforce greatly influences the quality of healthcare. When facing the crisis of physician shortages, the correction of manpower always takes an extended time period, and both the public and health personnel suffer. To calculate an appropriate number of Physician Density (PD) for a specific country, this study was designed to create a PD prediction model, based on health-related data from many countries. METHODS: Twelve factors that could possibly impact physicians' demand were chosen, and data of these factors from 130 countries (by reviewing 195) were extracted. Multiple stepwise-linear regression was used to derive the PD prediction model, and a split-sample cross-validation procedure was performed to evaluate the generalizability of the results. RESULTS: Using data from 130 countries, with the consideration of the correlation between variables, and preventing multi-collinearity, seven out of the 12 predictor variables were selected for entry into the stepwise regression procedure. The final model was: PD = (5.014 - 0.128 × proportion under age 15 years + 0.034 × life expectancy)2, with R2 of 80.4%. Using the prediction equation, 70 countries had PDs with "negative discrepancy", while 58 had PDs with "positive discrepancy". CONCLUSION: This study provided a regression-based PD model to calculate a "norm" number of PD for a specific country. A large PD discrepancy in a country indicates the needs to examine physician's workloads and their well-being, the effectiveness/efficiency of medical care, the promotion of population health and the team resource management.

A medical ethical reasoning model and its contributions to medical education.

OBJECTIVES: Ethical reasoning in medicine is not well understood and medical educators often find it difficult to justify what and how they teach and assess in medical ethics. To facilitate the development of moral values and professional conduct, a model of ethical reasoning was created. The purposes of this paper are to describe the ethical reasoning model and to indicate how it can be used to foster moral and ethical behaviours. METHODS: The ethical reasoning model was created from information derived from two sources: (i) an examination of different ethical models described in the literature, and (ii) think-aloud interviews with ethical experts in Taiwan and Canada. All the components and cognitive steps used by experts in ethical decision making were extracted and categorised. Interview subjects consisted of 16 voluntary ethics experts. The ethical reasoning models reported in the literature were divided into two groups according to whether they were justification-based or task-based models. Neither of the two types represented the 'whole picture' of ethical reasoning in medicine. This analysis enabled us to identify five universal cognitive steps and the gaps between 'logical decision' and 'action'. RESULTS: The think-aloud interviews verified the multi-dimensional components or steps used by experts when resolving ethical problems. The resulting model, designated the Medical Ethical Reasoning (MER) Model, reflects interactions within three domains: medical and ethical knowledge; cognitive reasoning processes, and attitude. CONCLUSIONS: The MER Model accurately reflects how doctors resolve ethical dilemmas and is seen to be helpful in identifying what and how educators should teach and assess in ethical reasoning. The model can also serve as a communication framework for curricular design. A 'humane' doctor is competent in providing quality, ethical patient care. Making an appropriate ethical decision is the foundation for subsequent ethical behaviours. By contrast with the abundant evidence cited in previous research describing how doctors solve medical problems, there is little empirical evidence indicating how doctors make appropriate ethical decisions. Thus, the cognition of ethical reasoning in medicine is not well understood. This paper represents a step towards overcoming this problem.

Effects of anxiety on dental students' noncognitive performance in their first objective structured clinical examination.

Patient-dentist discourse is a core nonoperational competency in dental education. The skills of querying patients and responding to questions are noncognitive attributes, and their evaluation by the standardized patient objective structured clinical examination (OSCE) is particularly necessary. However, it is not clear whether students' test anxiety affects these attributes. This study aims to examine the relationship between dental students' state-trait anxiety, noncognitive performance, and examination results during their first OSCE. A single dental school cohort (n = 226) of 5 year students attending their first clinical examination from 2014 to 2017 was studied. Participants completed the Chinese Mandarin Version State-Trait Anxiety Inventory Y form before taking the OSCE. The difference between state and trait anxiety levels was compared by paired t test. Gender differences and the effect of age group in these anxiety levels were analyzed using multivariate analysis of variance. Moreover, gender, age group, state anxiety, and trait anxiety scores were compared with the OSCE items of noncognitive performance using a chi-square test. Students showed significantly higher state anxiety than trait anxiety levels; moreover, women showed significantly higher state anxiety than men. Furthermore, gender, age group, state anxiety, and trait anxiety had no association with the noncognitive performance examination results. Most participants showed moderate state and trait anxiety levels during their first OSCE. Further, the state-trait anxiety had no significant effect on their noncognitive performance. However, 26.5% of participants did not pass the examination; therefore, dental educators should increase communication skill training courses during clerkship training to improve students' noncognitive attributes.

Screening young children with a first febrile urinary tract infection for high-grade vesicoureteral reflux with renal ultrasound scanning and technetium-99m-labeled dimercaptosuccinic acid scanning.

OBJECTIVE: To evaluate the predictive value of renal ultrasound scanning and 99m-Technetium-dimercaptosuccinic acid (DMSA) scintigraphy for high-grade vesicoureteral reflux (VUR) in young children with a first urinary tract infection (UTI). STUDY DESIGN: The medical records of children who had been examined with renal ultrasound scanning, DMSA scanning, and voiding cystourethrography (VCUG) were reviewed. The findings of renal ultrasound scanning, DMSA scanning, and their predictive values were evaluated. RESULTS: Of 699 children, high-grade VUR (grades III-V) was diagnosed in 119 (17.0%). Signs of renal hypodysplasia (OR, 16.15), cyclic dilatation of pelvicaliceal system (OR, 11.73), hydroureter (OR, 4.00) with renal ultrasound scanning, and renal hypodysplasia (OR, 8.78), acute pyelonephritis (OR, 2.76) with DMSA scanning were associated with high-grade VUR. The sensitivities for high-grade VUR of ultrasound scanning alone (67.2%) or DMSA scanning alone (65.5%) were not as good as that of a both-test strategy, which had a sensitivity rate of 83.2%. The negative predictive value of the both-test strategy was 91.5%. CONCLUSION: Renal ultrasound scanning and DMSA scanning both should be routinely performed in children with a first febrile UTI. VCUG is only indicated when abnormalities are apparent on either ultrasound scanning or DMSA scanning or both.

Assessing ethical problem solving by reasoning rather than decision making.

CONTEXT: The assessment of ethical problem solving in medicine has been controversial and challenging. The purposes of this study were: (i) to create a new instrument to measure doctors' decisions on and reasoning approach towards resolving ethical problems; (ii) to evaluate the scores generated by the new instrument for their reliability and validity, and (iii) to compare doctors' ethical reasoning abilities between countries and among medical students, residents and experts. METHODS: This study used 15 clinical vignettes and the think-aloud method to identify the processes and components involved in ethical problem solving. Subjects included volunteer ethics experts, postgraduate Year 2 residents and pre-clerkship medical students. The interview data were coded using the instruments of the decision score and Ethical Reasoning Inventory (ERI). The ERI assessed the quality of ethical reasoning for a particular case (Part I) and for an individual globally across all the vignettes (Part II). RESULTS: There were 17 Canadian and 32 Taiwanese subjects. Based on the Canadian standard, the decision scores between Taiwanese and Canadian subjects differed significantly, but made no discrimination among the three levels of expertise. Scores on the ERI Parts I and II, which reflect doctors' reasoning quality, differed between countries and among different levels of expertise in Taiwan, providing evidence of construct validity. In addition, experts had a greater organised knowledge structure and considered more relevant variables in the process of arriving at ethical decisions than did residents or students. The reliability of ERI scores was 0.70-0.99 on Part I and 0.75-0.80 on Part II. CONCLUSIONS: Expertise in solving ethical problems could not be differentiated by the decisions made, but could be differentiated according to the reasoning used to make those decisions. The difference between Taiwanese and Canadian experts suggests that cultural considerations come into play in the decisions that are made in the course of providing humane care to patients.

Paecilomyces lilacinus peritonitis complicating peritoneal dialysis cured by oral voriconazole and terbinafine combination therapy.

Fungal peritonitis (FP) is a serious complication in patients on continuous ambulatory peritoneal dialysis (CAPD). We report a case of CAPD-related FP caused by Paecilomyces lilacinus in a 15-year-old uraemic boy. The infection was successfully treated by combination therapy consisting of oral voriconazole and terbinafine, which has not been previously reported in the treatment of FP.

Current trends in developing medical students' critical thinking abilities.

Health care is fallible and prone to diagnostic and management errors. The major categories of diagnostic errors include: (1) no-fault errors--the disease is present but not detected; (2) system errors--a diagnosis is delayed or missed because of the imperfection in the health care system; and (3) cognitive errors--a misdiagnosis from faulty data collection or interpretation, flawed reasoning, or incomplete knowledge. Approximately one third of patient problems are mismanaged because of diagnostic errors. Part of the solution lies in improving the diagnostic skills and critical thinking abilities of physicians as they progress through medical school and residency training. However, this task is challenging since both medical problem-solving and the learning environments are complex and not easily understood. There are many interacting variables including the motivation of the medical student (e.g. deep versus surface learning), the acquisition and evolution of declarative and conditional knowledge (e.g. reduced, dispersed, elaborated, scheme, and scripted), problem-solving strategies (e.g. procedural knowledge-guessing, hypothetical deductive, scheme inductive, and pattern recognition), curricular models (e.g. apprenticeship, discipline-based, body system-based, case-based, clinical presentation-based), teaching strategies (e.g. teaching general to specific or specific to general), the presented learning opportunities (PBL versus scheme inductive PBL), and the nature of the learning environment (e.g. modeling critical thinking and expert problem-solving). This paper elaborates on how novices differ from experts and how novices can be educated in a manner that enhances their level of expertise and diagnostic abilities as they progress through several years of medical training.

Clinical differentiation of acute pyelonephritis from lower urinary tract infection in children.

BACKGROUND AND PURPOSE: To evaluate clinical variables for diagnosing childhood acute pyelonephritis (APN) when technetium-99m dimercaptosuccinic acid (DMSA) scintigraphy is not available. METHODS: We retrospectively reviewed the records of 590 children with febrile UTI seen from January 1999 to February 2004. On the basis of DMSA scintigraphy performed within 7 days after admission, they were divided into APN (n = 237) or non-APN (n = 353) groups. Gender, age, clinical presentation, absolute neutrophil count, C-reactive protein (CRP), urinalysis, culture, and sonographic findings were recorded from charts. RESULTS: A CRP level of > or =66.4 mg/L, in patients with >2 days prior to admission had a sensitivity of 71.6% and a specificity of 72.5% for APN. Similarly, a CRP of >27.3 mg/L in patients with < or =2 days prior to admission and a white cell count of >14,990/mm3 had sensitivities of 68.6% and 62.0% and specificities of 66.1% and 63.0%, respectively. Combining two or more variables did not result in better discrimination. CONCLUSIONS: If a DMSA scan is not available, it is reasonable to treat a febrile UTI as APN if the CRP is >66.4 mg/L in a patient with >2 days of fever or if the CRP is >27.3 mg/L in a patient febrile for < or =2 days.

Students' perception on medical professionalism: the psychometric perspective.

BACKGROUND: The main purpose of this study was to identify and understand the structure of latent traits underlying the concept of medical professionalism of Taiwanese students. METHODS: A 32 item questionnaire assessing medical professionalism derived from the definition by the American Board Internal Medicine (ABIM) was distributed to 133 year seven medical students. A five-point rating scale of importance was used to identify the extent of their values or beliefs in each item. RESULTS: The three items perceived most important were: accountability to patients, respect for patients and their families; and integrity and prudence. The least important component underlying professionalism was 'enduring unavoidable risks to oneself when a patient's welfare is at stake'. Factor analysis resulted in eight factors: 'commitment to care' (factor 1); 'righteous and rule-abiding' (factor 2); 'pursuing quality patient care' (factor 3), 'habit of professional practice' (factor 4); 'interpersonal relationship' (factor 5); 'patient-oriented' issues (factor 6); physician's 'self-development' (factor 7); and finally, 'respect for others' (factor 8). Most of the variance was contributed by factor 1 (34.9%). The mean score of factors ranged from 3.84 (factor 1: commitment to care) to 4.7 (factor 8: respect of others), and the reliability alphas ranged from 0.86 to 0.66. CONCLUSIONS: These results of young physicians' professional values have implications for medical school curriculum for improvement.

Resistance to medical educational change: management and communication.

Medical education in Taiwan is currently undergoing active renovation. Reform and changes always bring resistance from the levels of individuals, institution and even the society. As an educational leader, to be able to manage resistance is a key to successful reform. This review article provides management strategies and communication skills to solve the resistance problem. The best solution to the problem is "to prevent" resistance from happening through identifying those who may be reluctant to change, and the reasons behind the potential resistance. Some of the reasons for resistance are threatening of self-interest and a loss of face, excess uncertainty, conservatism, fear of personal-worth declination in the organization, and different assessment or perception. The management and communication strategies are suggested to adjust to fit reform process, i.e., recognizing the needs for change, planning process, implementation, and institutionalization innovation. Finally, it is only with respect, empathy, sincerity and support that the resistance to changes can be resolved and difficulties can be overcome.