Legitimate participation of medical students in community attachments.

INTRODUCTION: Social theories of learning consider learning and thinking as social activities. These activities may occur within a community of practice. Communities of practice may position learners as legitimate peripheral participants. This study tests whether legitimate peripheral participation provides an overarching theory to assist in evaluating learning and teaching of medical students undertaking short primary care attachments. METHODS: A questionnaire was delivered to all Year 4 students at the University of Auckland in 2015. A deductive content analysis was undertaken on the data utilising a categorisation matrix. Legitimate peripheral participation theory was used to develop the categorisation matrix. RESULTS: Three broad themes explained legitimate peripheral participation by medical students undertaking a short primary care attachment. These three themes were 'hospitality,' 'collegiality' and 'responsibility.' CONCLUSION: Legitimate peripheral participation, in the context of undergraduate primary health care attachments, appears to depend upon positive social activities between students and health professionals and patients. Using legitimate peripheral participation as a theory to underpin evaluations of general practice attachments it is possible to determine improvements in the learning and teaching experience of medical students.

Tips and Traps: Lessons From Codesigning a Clinician E-Monitoring Tool for Computerized Cognitive Behavioral Therapy.

BACKGROUND: Computerized cognitive behavioral therapy (cCBT) is an acceptable and promising treatment modality for adolescents with mild-to-moderate depression. Many cCBT programs are standalone packages with no way for clinicians to monitor progress or outcomes. We sought to develop an electronic monitoring (e-monitoring) tool in consultation with clinicians and adolescents to allow clinicians to monitor mood, risk, and treatment adherence of adolescents completing a cCBT program called SPARX (Smart, Positive, Active, Realistic, X-factor thoughts). OBJECTIVE: The objectives of our study were as follows: (1) assess clinicians' and adolescents' views on using an e-monitoring tool and to use this information to help shape the development of the tool and (2) assess clinician experiences with a fully developed version of the tool that was implemented in their clinical service. METHODS: A descriptive qualitative study using semistructured focus groups was conducted in New Zealand. In total, 7 focus groups included clinicians (n=50) who worked in primary care, and 3 separate groups included adolescents (n=29). Clinicians were general practitioners (GPs), school guidance counselors, clinical psychologists, youth workers, and nurses. Adolescents were recruited from health services and a high school. Focus groups were run to enable feedback at 3 phases that corresponded to the consultation, development, and postimplementation stages. Thematic analysis was applied to transcribed responses. RESULTS: Focus groups during the consultation and development phases revealed the need for a simple e-monitoring registration process with guides for end users. Common concerns were raised in relation to clinical burden, monitoring risk (and effects on the therapeutic relationship), alongside confidentiality or privacy and technical considerations. Adolescents did not want to use their social media login credentials for e-monitoring, as they valued their privacy. However, adolescents did want information on seeking help and personalized monitoring and communication arrangements. Postimplementation, clinicians who had used the tool in practice revealed no adverse impact on the therapeutic relationship, and adolescents were not concerned about being e-monitored. Clinicians did need additional time to monitor adolescents, and the e-monitoring tool was used in a different way than was originally anticipated. Also, it was suggested that the registration process could be further streamlined and integrated with existing clinical data management systems, and the use of clinician alerts could be expanded beyond the scope of simply flagging adolescents of concern. CONCLUSIONS: An e-monitoring tool was developed in consultation with clinicians and adolescents. However, the study revealed the complexity of implementing the tool in clinical practice. Of salience were privacy, parallel monitoring systems, integration with existing electronic medical record systems, customization of the e-monitor, and preagreed monitoring arrangements between clinicians and adolescents.

Students' responses to scenarios depicting ethical dilemmas: a study of pharmacy and medical students in New Zealand.

One of the key learning objectives in any health professional course is to develop ethical and judicious practice. Therefore, it is important to address how medical and pharmacy students respond to, and deal with, ethical dilemmas in their clinical environments. In this paper, we examined how students communicated their resolution of ethical dilemmas and the alignment between these communications and the four principles developed by Beauchamp and Childress. Three hundred and fifty-seven pharmacy and medical students (overall response rate=63%) completed a questionnaire containing four clinical case scenarios with an ethical dilemma. Data were analysed using multiple methods. The findings revealed that 73% of the qualitative responses could be exclusively coded to one of the 'four principles' determined by the Beauchamp and Childress' framework. Additionally, 14% of responses overlapped between the four principles (multiple codes) and 13% of responses could not be coded using the framework. The subsequent subgroup analysis revealed different response patterns depending on the case being reviewed. The findings showed that when students are faced with challenging ethical dilemmas their responses can be aligned with the Beauchamp and Childress framework, although more contentious dilemmas involving issues of law are less easily categorised. The differences between year and discipline groups show students are developing ethical frames of reference that may be linked with their teaching environments and their levels of understanding. Analysis of these response patterns provides insight into the way students will likely respond in 'real' settings and this information may help educators prepare students for these clinical ethical dilemmas.

The relationship between quality of life and spirituality, religiousness, and personal beliefs of medical students.

OBJECTIVE: This study investigated the effects of spirituality, religiousness, and personal beliefs on the quality of life (QOL) of medical students affiliated with a religious faith and those without affiliation. METHODS: Using a cross-sectional design, 275 medical students (78 % response rate) in their fourth and fifth year of study completed the WHOQOL-BREF quality of life instrument and the WHOQOL-SRPB module for spirituality, religiousness, and personal beliefs. RESULTS: For religious students, a larger range of characteristics of existential beliefs were positively related to quality of life. For all students, hope and optimism and meaning of life predicted higher scores on psychological. CONCLUSIONS: For religious and nonreligious medical students, reduced meaning in life and hope were the strongest indicators of psychological distress. Interventions to improve the mental well-being of medical students may be more effective if aimed at teaching students how to find meaning and purpose in their lives and how to foster an enduring sense of hope and optimism.

Religious affiliation, quality of life and academic performance: New Zealand medical students.

The present study investigated the connections between religious affiliation, quality of life (QOL) and measures of academic performance. Participants (n = 275) were recruited from the School of Medicine within a New Zealand university. Religious affiliation was classified according to three subcategories: Christian (n = 104), Eastern religion (n = 34) and non-religious (n = 117). The participants completed the World Health Organisation quality of life questionnaire (WHOQOL-BREF) and the World Health Organisation Spiritual, Religiousness, and Personal Beliefs questionnaire immediately before their lecture time. The main findings of the study indicated that participants from different religious affiliations expressed different spiritual QOL perceptions. However, these different expressions did not translate into their perceptions related to hours of study and academic achievement. In addition, the QOL measures did not relate to academic achievement estimation but did predict hours of study. Greater hours of study were related to greater physical health but lower psychological health and poorer engagement in developing social relationships. Data from a small focus group (n = 4) revealed that these students believed that having a belief system assisted them when coping with the academic learning environment, although little difference could be found between external religious orientations and internal belief systems.

Junior doctors in their first year: mental health, quality of life, burnout and heart rate variability.

There is a burgeoning interest in, and evidence of, quality of life and burnout issues among doctors. It was hypothesized that the junior doctors in this study would experience psychosocial and physiological changes over time, and that the obtained measures would indicate psychosocial and physiological anomalies. In addition, it was hypothesized that their psychosocial perceptions would be significantly associated with their physiological measures. A total sample of 17 junior doctors in their first year of training volunteered for this study. Over four time periods separated by 6 week phases, the doctors completed a set of quality of life and psychosocial inventories and wore a Polar RS800 Heart Rate Monitor over a day and night time interval. The findings showed that this sample of doctors did not report any problems associated with depression, anxiety, stress, burnout or quality of life (psychosocial measures). In addition, their heart rate variability scores (physiological measures) did not show any significant fluctuations. Furthermore, the responses from the self-report instruments measuring stress, anxiety, depression, quality of life and burnout did not consistently correlate with the HRV information suggesting a mind-body disconnection. More work needs to be done on larger samples to investigate these findings further given that the literature shows that junior doctors are likely to be stressed and working in stress-provoking environments.

Reasons for academic honesty and dishonesty with solutions: a study of pharmacy and medical students in New Zealand.

This paper presents students' views about honest and dishonest actions within the pharmacy and medical learning environments. Students also offered their views on solutions to ameliorating dishonest action. Three research questions were posed in this paper: (1) what reasons would students articulate in reference to engaging in dishonest behaviours? (2) What reasons would students articulate in reference to maintaining high levels of integrity? (3) What strategies would students suggest to decrease engagement in dishonest behaviours and/or promote honest behaviours? The design of the study incorporated an initial descriptive analysis to interpret students' responses to an 18-item questionnaire about justifications for dishonest action. This was followed by a qualitative analysis of students' commentaries in reference to why students would engage in either honest or dishonest action. Finally a qualitative analysis was conducted on students' views regarding solutions to dishonest action. The quantitative results showed that students were more likely to use time management and seriousness justifications for dishonest actions. The qualitative findings found that students' actions (honest or dishonest) were guided by family and friends, the need to do well, issues of morality and institutional guidelines. Students suggested that dishonest action could be ameliorated by external agencies and polarised views between punitive and rewards-based mechanisms were offered. These results suggest that these students engaged in dishonest action for various reasons and solutions addressing dishonest action need to consider diverse mechanisms that likely extend beyond the educational institution.

Medical students' and clinical teachers' perceptions of Maori health teaching.

AIMS: To investigate the views of medical students early in their clinical training and their clinical teachers with respect to Maori health teaching and learning. METHOD: A survey approach was used to appraise responses from 276 students early in their clinical training and 135 clinical teachers. All participants were asked to respond to a set of questions about the teaching and assessment of Hauora Maori (Maori health). These responses were analysed using descriptive statistics and inspection of the distribution of responses (skewness and kurtosis). A further open ended question was asked about suggested changes to the medical school and the responses relating to Hauora Maori were analysed using a summative content analysis system. RESULTS: The distribution of the data revealed strongly skewed responses in the direction of disagreement in relation to four of the six student questionnaire items indicating that most students question the quality of Hauora Maori teaching and assessment. Also, two of the five items from the clinical teacher questionnaire were strongly skewed to the disagreement option suggesting that many clinical teachers felt underprepared to teach this aspect of the curriculum. The content analysis identified a range of views, often polarised, with responses at the negative end of the spectrum revealing a degree of resistance to Maori health teaching and learning. CONCLUSIONS: The findings of this study raise concerns about the extent to which medical students are supported to achieve Hauora Maori learning outcomes. The consistency between medical student and clinical teacher findings points to systemic issues, and the solutions are likely to be multi-layered. At the institutional level, Maori health needs to be consistently presented as a legitimate and critical area of medical education. At the educational level, it is important that all teachers are supported to provide high quality teaching, learning and assessment of Hauora Maori across the curriculum.

General surgical interns contributing to the clerkship learning environment of medical students.

BACKGROUND: Junior doctors are increasingly promoted as clinical teachers but there is limited understanding of how they contribute to medical student clerkship learning. AIM: To describe contributions made by general surgical interns to the student clerkship learning environment. METHODS: The mixed-methods study involved two focus groups attended by volunteer interns and Year 4 students, and a student questionnaire collecting quantitative data. Focus group transcripts were evaluated using a qualitative analysis system. RESULTS: Six interns and five students attended focus groups in June and August 2011. Qualitative analysis found that intern contributions to student learning can be grouped under four distinct roles: physician, supervisor, teacher and person. Data from 85 questionnaires (response rate 57%) revealed that intern-student encounters occurred daily in the surgical wards and emergency department. Interns demonstrated bedside procedures, clerical/administrative tasks and interpretation of laboratory and radiological investigations. Appreciated for approachability, friendliness and ability to relate to students, interns also played a crucial role in integrating students into the surgical team. This significantly correlated to clerkship enjoyment. CONCLUSIONS: Surgical interns improve clerkship learning environments by demonstrating "personal" skills such as friendliness, approachability and relatedness. This has important implications for preparing interns as clinical preceptors.

Academic dishonesty and ethical reasoning: pharmacy and medical school students in New Zealand.

BACKGROUND: There is ample evidence to suggest that academic dishonesty remains an area of concern and interest for academic and professional bodies. There is also burgeoning research in the area of moral reasoning and its relevance to the teaching of pharmacy and medicine. AIMS: To explore the associations between self-reported incidence of academic dishonesty and ethical reasoning in a professional student body. METHODS: Responses were elicited from 433 pharmacy and medicine students. A questionnaire eliciting responses about academic dishonesty (copying, cheating, and collusion) and their decisions regarding an ethical dilemma was distributed. Multivariate analysis procedures were conducted. RESULTS: The findings suggested that copying and collusion may be linked to the way students make ethical decisions. Students more likely to suggest unlawful solutions to the ethical dilemma were more likely to disclose engagement in copying information and colluding with other students. CONCLUSIONS: These findings imply that students engaging in academic dishonesty may be using different ethical frameworks. Therefore, employing ethical dilemmas would likely create a useful learning framework for identifying students employing dishonest strategies when coping with their studies. Increasing understanding through dialog about engagement in academic honesty will likely construct positive learning outcomes in the university with implications for future practice.

The quality of life of medical students studying in New Zealand: a comparison with nonmedical students and a general population reference group.

BACKGROUND: Quality of life is an essential component of learning and has strong links with the practice and study of medicine. There is burgeoning evidence in the research literature to suggest that medical students are experiencing health-related problems such as anxiety, depression, and burnout. PURPOSE: The aim of the study was to investigate medical students' perceptions concerning their quality of life. METHODS: Two hundred seventy-four medical students studying in their early clinical years (response rate = 80%) participated in the present study. Medical students were asked to fill in the abbreviated version of the World Health Organization Quality of Life questionnaire to elicit information about their quality of life perceptions in relation to their physical health, psychological health, social relationships, and environment. Subsequently, their responses were compared with two nonmedical students groups studying at a different university in the same city and an Australian general population norm. The findings were compared using independent group's t tests, confidence intervals, and Cohen's d. RESULTS: The main finding of the study indicated that medical students had similar quality of life perceptions to nonmedical students except in relation to the environment domain. Furthermore, the medical student group scored lower than the general population reference group on the physical health, psychological health, and environment quality of life domains. CONCLUSIONS: The results suggest that all university students are expressing concerns related to quality of life, and thus their health might be at risk. The findings in this study provided no evidence to support the notion that medical students experience lower levels of quality of life compared to other university students. When compared to the general population, all student groups examined in this study appeared to be experiencing lower levels of quality of life. This has implications for pastoral support, educationalists, student support personnel, and the university system.

Consensus statement from the Health of the Health Professional Conference, November 2011.

This article presents a consensus statement that arose from the views of participants that attended the multidisciplinary conference "The Health of the Health Professional", in Auckland in November 2011. A healthy workforce is the key to improving the health of all New Zealanders. Yet health practitioners' health is of concern, and despite the evidence of real problems little has been done to constructively and systematically address these issues. This consensus statement provides some potential ways to move forward.

Impact of a Resident-as-Teacher Workshop on Teaching Behavior of Interns and Learning Outcomes of Medical Students.

BACKGROUND: Residents and interns are recognized as important clinical teachers and mentors. Resident-as-teacher training programs are known to improve resident attitudes and perceptions toward teaching, as well as their theoretical knowledge, skills, and teaching behavior. The effect of resident-as-teacher programs on learning outcomes of medical students, however, remains unknown. An intervention cohort study was conducted to prospectively investigate the effects of a teacher-training workshop on teaching behavior of participating interns and on the clerkship learning outcomes of instructed fourth-year medical students. METHODS: The House Officer-as-Teacher Training Workshop was implemented in November 2009 over 1.5 days and attended by all 34 interns from one teaching hospital. Subsequently, between February and August 2010, 124 fourth-year medical students rated the observable teaching behavior of interns during 6-week general surgery clerkships at this intervention hospital as well as at 2 comparable hospitals serving as control sites. Ratings were collected using an anonymous 15-item Intern Clinical Teaching Effectiveness Instrument. Student achievement of clerkship learning outcomes during this period was evaluated using a validated and centralized objective structured clinical examination. RESULTS: Medical students completed 101 intern clinical teaching effectiveness instruments. Intern teaching behavior at the intervention hospital was found to be significantly more positive, compared with observed behavior at the control hospitals. Objective structured clinical examination results, however, did not demonstrate any significant intersite differences in student achievement of general surgery clerkship learning outcomes. CONCLUSIONS: The House Officer-as-Teacher Training Workshop noticeably improved teaching behavior of surgical interns during general surgery clerkships. This improvement did not, however, translate into improved achievement of clerkship learning outcomes by medical students during the study period.

Quality of life: international and domestic students studying medicine in New Zealand.

International students form a significant proportion of students studying within universities in Western countries. The quality of life perceptions of international medical students in comparison with domestic medical students has not been well documented. There is some evidence to suggest that international medical students may have different educational and social experiences in relation to their domestic peers. This study investigates the levels of quality of life experienced by international and domestic students studying medicine. A total of 548 medical students completed the abbreviated version of the World Health Organization Quality of Life questionnaire. The focus of the analysis was to evaluate differences between international and domestic students in their early clinical years. The responses were analysed using multivariate analysis of variance methods. International medical students are experiencing lower social and environmental quality of life compared with domestic peers. International medical students in New Zealand have expressed quality of life concerns, which likely have an impact on their academic achievement, feelings of wellness, acculturation, and social adaptation. The findings reinforce the need for creating stronger social networks and accessible accommodation, as well as developing systems to ensure safety, peer mentorship and student support.

Clinical teachers working in primary care: what would they like changed in the medical school?

INTRODUCTION: General practitioners (GPs) working as clinical teachers are likely to influence medical students' level of community-based learning. This paper aimed to ascertain clinical teachers' views in relation to The University of Auckland about their clinical learning environment. METHOD: A total of 34 clinical teachers working in primary care contributed to this study. To gauge their level of involvement in teaching and learning, the clinical teachers were asked about issues such as their confidence, available time, sufficient clinical learning opportunities, clear learning objectives to teach students and what they would like changed. FINDINGS: The GPs appeared confident, felt there were sufficient learning opportunities for students and that their students were part of the team. Less experienced teachers expressed less confidence than more experienced peers. There was some hesitancy in terms of coping with time and feedback. Some clinical teachers were unclear about the learning objectives presented to students. CONCLUSION: Several issues that emerged--including available time and financial rewards--are difficult to resolve. Curriculum and selection are evolving issues requiring constant monitoring and alignment with increasing numbers of students studying medicine, increased ethical awareness, more diverse teaching systems and more advanced technologies. Non-faculty clinicians need adequate representation on curriculum committees and involvement in clinical education initiatives. Issues of cultural competency and professional development were raised, suggesting the need for more established links between university and GPs.

Students' and teachers' perceptions of the clinical learning environment in years 4 and 5 at the University of Auckland.

AIM: As the undergraduate medical curriculum is developed in response to an increasing number of students across multiple teaching sites, it is timely to review the clinical learning environment of medical students in the first two clinical years. METHOD: University of Auckland students in year 4 and 5 completed the Dundee Ready Educational Environment Measure (DREEM). Clinical Teachers completed a shorter questionnaire on their perceptions of the clinical learning environment. RESULTS: The students perceive their clinical learning environment positively and their perceptions compare favourably with similar studies internationally. The DREEM is reliable for and practical to use in the New Zealand undergraduate clinical learning environment. Learning site, year of study, clinical team, gender, age, or ethnicity did not influence students' perceptions of their learning environment. Clinical teachers view their teaching positively but there seem to be concerns over the amount of time they have available for teaching. CONCLUSION: Students are concerned about the amount of knowledge they need to acquire and the availability of support for students under stress as they enter and during the clinical years. Clinical teachers are concerned about the amount of time they have available for teaching.

Changing the learning environment: the medical student voice.

BACKGROUND: Students' perceptions of their learning environment influence both how they learn and the quality of their learning outcomes. The clinical component of undergraduate medical courses takes place in an environment designed for clinical service and not teaching. Tension results when these two activities compete for resources. An impending increase in medical student numbers led us to assess the learning environment with a view to planning for the future. METHODS: An open ended question 'If you could change three things about medical school, what would they be?' was added to the Dundee Ready Educational Environment Measure (DREEM). This was used to assess the learning environment of students in years 4 and 5. Allowing students to actively voice their views about changes in the curriculum was considered a useful extension to the DREEM questionnaire. RESULTS: The findings indicated commonalities over the two years of clinical teaching. The areas of commonality included the need for: more clinical exposure early in the curriculum; fewer lectures; greater consistency in terms of assessment; and more constructive relationships. Fourth-year students tended to voice more concerns around resourcing, and sought more clarification about roles and learning outcomes. DISCUSSION: There is a need to address concerns raised by students in the areas of curricula, assessments and access to earlier clinical training. Concerns that can be addressed are increasing resource access, implementation of clearer objectives, consistency of teaching and assessments across sites, more formative assessments, and engaging feedback. Students would also benefit from substantive mentoring and role-modelling.

Medical students-as-teachers: a systematic review of peer-assisted teaching during medical school.

INTRODUCTION: International interest in peer-teaching and peer-assisted learning (PAL) during undergraduate medical programs has grown in recent years, reflected both in literature and in practice. There, remains however, a distinct lack of objective clarity and consensus on the true effectiveness of peer-teaching and its short- and long-term impacts on learning outcomes and clinical practice. OBJECTIVE: To summarize and critically appraise evidence presented on peer-teaching effectiveness and its impact on objective learning outcomes of medical students. METHOD: A literature search was conducted in four electronic databases. Titles and abstracts were screened and selection was based on strict eligibility criteria after examining full-texts. Two reviewers used a standard review and analysis framework to independently extract data from each study. Discrepancies in opinions were resolved by discussion in consultation with other reviewers. Adapted models of "Kirkpatrick's Levels of Learning" were used to grade the impact size of study outcomes. RESULTS: From 127 potential titles, 41 were obtained as full-texts, and 19 selected after close examination and group deliberation. Fifteen studies focused on student-learner outcomes and four on student-teacher learning outcomes. Ten studies utilized randomized allocation and the majority of study participants were self-selected volunteers. Written examinations and observed clinical evaluations were common study outcome assessments. Eleven studies provided student-teachers with formal teacher training. Overall, results suggest that peer-teaching, in highly selective contexts, achieves short-term learner outcomes that are comparable with those produced by faculty-based teaching. Furthermore, peer-teaching has beneficial effects on student-teacher learning outcomes. CONCLUSIONS: Peer-teaching in undergraduate medical programs is comparable to conventional teaching when utilized in selected contexts. There is evidence to suggest that participating student-teachers benefit academically and professionally. Long-term effects of peer-teaching during medical school remain poorly understood and future research should aim to address this.

In search of professionalism: implications for medical education.

This is the seventh article in an education series, discussing some of the 'hot topics' in teaching and learning in medicine. Historically, 'professionalism' was defined by the social structures of medicine, but has moved on to represent the expected behaviours and attributes of practitioners. Well publicised cases of professional misconduct, the rise of medical ethics as a discipline, and the move to a more patient-centred approach have driven the profile of professionalism into mainstream medical education. While there are many definitions of medical professionalism, there is a growing degree of consensus around what it encompasses; the way we manage tasks, our interactions with others, and looking after ourselves. The literature indicates that professionalism can be taught, learnt and applied; that attributes and behaviours can be identified; and that assessment is best approached using a range of methods over time. For learners, one of the critical factors in developing professionalism is the modelling by senior members of the profession as students move from peripheral observers to legitimate participants. Medical programmes in New Zealand are engaging with this literature in developing current curricula.