Bone morphogenetic proteins. Development and clinical efficacy in the treatment of fractures and bone defects.

The discovery of bone morphogenetic proteins marks a major step forward in the understanding of bone physiology and in the development of advanced methods in skeletal surgery. The cornerstones for successful growth-factor therapy in skeletal surgery remain biomechanical stability and biological vitality of the bone providing an adequate environment for new bone formation. Knowledge of the biological characteristics, mechanisms of action, and methods of delivery of growth factors will become essential for skeletal surgeons. The current clinical application of bone morphogenetic proteins is safe and efficacious as a result of a well-regulated cascade of events leading to bone formation. Clinical trials have not yet determined whether different clinical indications each require a specific bone-tissue-engineering format or if a single pathway for stimulating bone-healing with growth factors is sufficient.

How effective is a clerkship as a learning environment?

To assess the educational quality of a traditional clerkship, a questionnaire was administered to 28 students at the end of their 10-week surgical clerkship. The questionnaire contained 116 items on learning objectives, patient problems encountered by students, clinical skills performed, feedback received and amounts of time spent on various activities. The students indicated that they had adequate ability to correctly analyse and manage patient problems. However, the standard deviations and ranges show that individual students' exposure to various patient problems was insufficient. Students generally saw too few emergency patients. The frequencies of performance of diagnostic and therapeutic skills varied widely among students. Most of the feedback received by students was given by residents rather than faculty physicians. Students spent considerable time on activities of limited educational value. It appears that learning during a clerkship occurs rather haphazardly. There are indications that the 'educational exposure' varies substantially from student to student.

Reliability of the clinical teaching effectiveness instrument.

INTRODUCTION: The Clinical Teaching Effectiveness Instrument (CTEI) was developed to evaluate the quality of the clinical teaching of educators. Its authors reported evidence supporting content and criterion validity and found favourable reliability findings. We tested the validity and reliability of this instrument in a European context and investigated its reliability as an instrument to evaluate the quality of clinical teaching at group level rather than at the level of the individual teacher. METHODS: Students participating in a surgical clerkship were asked to fill in a questionnaire reflecting a student-teacher encounter with a staff member or a resident. We calculated variance components using the urgenova program. For individual score interpretation of the quality of clinical teaching the standard error of estimate was calculated. For group interpretation we calculated the root mean square error. RESULTS: The results did not differ statistically between staff and residents. The average score was 3.42. The largest variance component was associated with rater variance. For individual score interpretation a reliability of > 0.80 was reached with 7 ratings or more. To reach reliable outcomes at group level, 15 educators or more were needed with a single rater per educator. DISCUSSION: The required sample size for appraisal of individual teaching is easily achievable. Reliable findings can also be obtained at group level with a feasible sample size. The results provide additional evidence of the reliability of the CTEI in undergraduate medical education in a European setting. The results also showed that the instrument can be used to measure the quality of teaching at group level.

The impact of multifaceted educational structuring on learning effectiveness in a surgical clerkship.

INTRODUCTION: Various measures have been introduced to enhance learning experiences in clerkships, generally with limited success. This study evaluated the impact of a multifaceted approach on the effectiveness of learning in a surgical clerkship. In accordance with results obtained in continuing medical education, several interventions were introduced simultaneously. We compared students' evaluations of the traditional surgical clerkship with those of the restructured clerkship. METHODS: Two consecutive cohorts of students were asked to complete a questionnaire about the quality and quantity of their learning experiences. Cohort 1 (n = 28) undertook the traditional clerkship and cohort 2 (n = 72) the restructured clerkship. A Mann-Whitney test was used to compare outcomes between the 2 cohorts. RESULTS: There were few statistically significant differences between cohorts 1 and 2. Overall, quality indicators did not differ between the 2 cohorts. DISCUSSION: A short-term multifaceted intervention led to a slight increase in the performance of clinical skills and a slight decrease in time spent on activities of limited educational value. The intervention may have been too brief to produce substantial effects. Future interventions should also target teachers, including trainees, in order to assess their opinions and address their educational needs.

A qualitative study of constructive clinical learning experiences.

Little is known about the effectiveness of clinical education. A more educational structure is considered to be potentially beneficial. The following structured components were added to a surgical clerkship: logbooks, an observed student-patient encounter, individual appraisals, feedback on patient notes, and (case) presentations by students. The authors organized two focus-group sessions in which 19 students participated to explore their perceptions about effective clinical learning experiences and the newly introduced structured components. The analysis of the transcripts showed that observation and constructive feedback are key features of clinical training. The structured activities were appreciated and the results show the direction to be taken for further improvement. Learning experiences depended vastly on individual clinicians' educational qualities. Students experienced being on call, assisting in theatre and time for self-study as instructive elements. Recommended clerkship components are: active involvement of students, direct observation, selection of teachers, a positive learning environment and time for self-study.