Conscientious, competent and caring: producing the junior doctor of the future.

This article is based on the Association for the Study of Medical Education Gold Medal Plenary for 2022, given by the first author. It outlines different ways in which medical training can be approached, based on his career and his work with colleagues. Among the attributes that it would be desirable to promote in future doctors are conscientiousness, competence and care for patients as individuals. This article explores each of these in separate sections. The first demonstrates that the trait of conscientiousness can be observed in first and second year medical students by their compliance in routine low level tasks such as attendance and submission of required work on time. A 'conscientiousness index' calculated on this basis is a statistically significant predictor of later events such as performance in exams, the prescribing safety assessment, and the UK situational judgement test in subsequent years, and also in postgraduate assessments such as Royal college exams and the annual reviews of competence progression. The second proposes that competence in tasks undertaken by junior doctors is better achieved by teaching on medical imaging, clinical skills and living anatomy than by cadaveric dissection. The final section argues that the incorporation of arts and humanities teaching into medical education is likely to lead to better understanding of the patient perspective in later practice.

An inexpensive retrospective standard setting method based on item facilities.

BACKGROUND: Standard setting is one of the most challenging aspects of assessment in high-stakes healthcare settings. The Angoff methodology is widely used, but poses a number of challenges, including conceptualisation of the just-passing candidate, and the time-cost of implementing the method. Cohen methodologies are inexpensive and rapid but rely on the performance of an individual candidate. A new method of standard setting, based on the entire cohort and every item, would be valuable. METHODS: We identified Borderline candidates by reviewing their performance across all assessments in an academic year. We plotted the item scores of the Borderline candidates in comparison with Facility for the whole cohort and fitted curves to the resulting distribution. RESULTS: It is observed that for any given Item, an equation of the form y ≈ C. eFx where y is the Facility of Borderline candidates on that Item, x is the observed Item Facility of the whole cohort, and C and F are constants, predicts the probable Facility for Borderline candidates over the test, in other words, the cut score for Borderline candidates. We describe ways of estimating C and F in any given circumstance, and suggest typical values arising from this particular study: that C = 12.3 and F = 0.021. CONCLUSIONS: C and F are relatively stable, and that the equation y = 12.3. e0.021x can rapidly be applied to the item Facility for every item. The average value represents the cut score for the assessment as a whole. This represents a novel retrospective method based on test takers. Compared to the Cohen method which draws on one score and one candidate, this method draws on all items and candidates in a test. We propose that it can be used to standard set a whole test, or a particular item where the predicted Angoff score is very different from the observed Facility.

'10% of your medical students will cause 90% of your problems': a prospective correlational study.

OBJECTIVES: Our aim was to explore the relationship between medical student Conscientiousness Index scores and indicators of later clinical performance held in the UK Medical Education Database (UKMED). Objectives were to determine whether conscientiousness in first-year and second-year medical students predicts later performance in medical school and in early practice. Policy implications would permit targeted remediation where necessary or aid in selection. DESIGN: A prospective correlational study. SETTING: A single UK medical school and early years of practice, 2005-2018. PARTICIPANTS: The data were obtained from the UKMED on 858 students. Full outcome data was available for variable numbers of participants, as described in the text. MAIN OUTCOME MEASURES: Scores on the UK Foundation Programme Office's Situational Judgement Test (SJT) and Educational Performance Measure (EPM), the Prescribing Safety Assessment (PSA) and Annual Review of Competency Progression (ARCP) outcomes. RESULTS: Linear regression analysis shows Conscientiousness Index scores significantly correlate with pregraduate and postgraduate performance variables: SJT scores (R=0.373, R2=0.139, B=0.066, p<0.001, n=539); PSA scores (R=0.249, R2=0.062, B=0.343, p<0.001, n=462); EPM decile scores for the first (lowest) decile are significantly lower than the remaining 90% (p=0.003, n=539), as are PSA scores (p<0.001, n=463), and ARCP year 2 scores (p=0.019, n=517). The OR that students in the first decile fail to achieve the optimum ARCP outcome is 1.6126 (CI: 1.1400 to 2.2809, p=0.0069, n=618). CONCLUSIONS: Conscientiousness Index scores in years 1 and 2 of medical school have predictive value for later performance in knowledge, skills and clinical practice. This trait could be used either for selection or for targeted remediation to avoid potential problems in the future.

A study to investigate the effectiveness of SimMan® as an adjunct in teaching preclinical skills to medical students.

BACKGROUND: Following the GMC's report on Tomorrow's Doctors, greater emphasis has been placed on training in clinical skills, and the integration of clinical and basic sciences within the curriculum to promote the development of effective doctors. The use of simulation in the learning environment has the potential to support the development of clinical skills in preclinical medical students whilst in a 'safe' environment, but currently there is little evidence on its effectiveness. METHODS: Seventy nine year one medical students were divided into two groups. A pre-test was conducted by both groups, after which one group performed chest examination on their peers whilst the other group examined the SimMan® manikin. Both groups subsequently performed a mid-test and crossed over so that the group that conducted peer examination examined the manikin and vice-versa. Finally a post-test was conducted. The students were scored for formative feedback whilst performing examinations. Students completed a feedback questionnaire at the end of the session. Data were analysed using a one-way ANOVA, independent t-test and 2- proportion Z test. RESULTS: When the two groups were compared, there was no significant difference in their pre-test and post-test knowledge scores, whereas mid-test knowledge scores increased significantly (P < 0.001), with the group using SimMan® initially scoring higher. A significant increase in the test scores was seen in both groups after using SimMan® (P < 0.001). Students' confidence increased significantly in differentiating between normal and abnormal signs (P < 0.001). Students highly valued the use of the manikin in the session with 96% of students reporting that it enhanced their learning experience. CONCLUSIONS: The study demonstrated a significant improvement in the students' knowledge after examining the manikin and students also reported an increase in their confidence. Students' feedback was generally very positive and they perceived the incorporation of manikin-based examinations useful to prepare them for future patient contact. The use of simulation in this context supports an integrated learning approach when used as an adjunct to peer examination, and can benefit the acquisition of clinical skills in preclinical medical students.

The 'unskilled and unaware' effect is linear in a real-world setting.

Self-assessment ability in medical students and practising physicians is generally poor, yet essential for academic progress and professional development. The aim of this study was to determine undergraduate medical students' ability to self-assess their exam performance accurately in a real-world, high-stakes exam setting, something not previously investigated. Year 1 and Year 2 medical students (n = 74) participated in a self-assessment exercise. Students predicted their exam grade (%) on the anatomy practical exam. This exercise was completed online immediately after the exam. Students' predicted exam grades were correlated with their actual attained exam grades using a Pearson's correlation. Demographic data were analysed using an independent t-test. A negative correlation was found between students' overall predicted and attained exam grades (P < 0.0001). There was a significant difference between the students' predicted grades and actual grades in the bottom, 3rd and top (P < 0.0001), but not 2nd quartiles of participants. There was no relationship between the students' entry status into medical school and self-assessment ability (Year 1: P = 0.112; Year 2: P = 0.236) or between males and females (Year 1: P = 0.174). However, a relationship was determined for these variables in Year 2 (P = 0.022). The number of hours of additional self-directed learning undertaken did not influence students' self-assessment in both years. Our results demonstrate the 'unskilled and unaware' phenomenon in a real-world, high-stakes and practice-related setting. Students in all quartiles were unable to self-assess their exam performance, except for a group of mid-range students in the 2nd quartile. Poor performers were shown to overestimate their ability and, conversely, high achievers to underestimate their performance. We present evidence of a strong, significant linear relationship between medical students' ability to self-assess their performance in an anatomy practical exam, and their actual performance; in a real world setting. Despite the limited ability to self-assess reported in the literature, our results may inform approaches to revalidation, which currently frequently rely on an ability to self-assess.

The clinical conscientiousness index: a valid tool for exploring professionalism in the clinical undergraduate setting.

PURPOSE: The need to develop effective tools to measure professionalism continues to challenge medical educators; thus, as a follow-up to a recent examination of the "Conscientiousness Index" (CI, a novel measure of one facet of professionalism) in one setting with preclinical medical students, the authors aimed to investigate the validity of the CI as a proxy measure of professionalism in a different context and in the clinical phase of undergraduate medical education. METHOD: In academic year 2009-2010, the authors collected data similar to those collected for the original preclinical study. In an effort to create a Clinical Conscientiousness Index (CCI) score, they collected the following information on 124 third-year medical students completing their clinical rotations: attendance, timeliness of assessment submissions, and completion of rotation evaluations. Then, they compared the resultant CCI scores with faculty views on professionalism and with formal assessments of students' professionalism (i.e., their portfolios and objective structured clinical examinations [OSCEs]). RESULTS: The authors demonstrate significant correlations between CCI scores and faculty views on professionalism (rS = 0.3; P = .001), and between CCI scores and OSCE score (rS = 0.237; P = .008), but not between CCI scores and portfolio assessment (rS = 0.084; P = .354). The authors also present relationships between CCI scores and demographics. CONCLUSION: The CCI is a practical, valid proxy measure of professionalism, achieving good correlation with faculty views on professionalism and clinical competency examinations, but not portfolio assessment, in one clinical undergraduate setting.

Ultrasound and cadaveric prosections as methods for teaching cardiac anatomy: a comparative study.

This study compared the efficacy of two cardiac anatomy teaching modalities, ultrasound imaging and cadaveric prosections, for learning cardiac gross anatomy. One hundred and eight first-year medical students participated. Two weeks prior to the teaching intervention, students completed a pretest to assess their prior knowledge and to ensure that groups were equally randomized. Students, divided into pre-existing teaching groups, were assigned to one of two conditions; "cadaver" or "ultrasound." Those in the cadaver group received teaching on the heart using prosections, whereas the ultrasound group received teaching using live ultrasound images of the heart. Immediately after teaching, students sat a post-test. Both teaching modalities increased students' test scores by similar amounts but no significant difference was found between the two conditions, suggesting that both prosections and ultrasound are equally effective methods for teaching gross anatomy of the heart. Our data support the inclusion of either cadaveric teaching or living anatomy using ultrasound within the undergraduate anatomy curriculum, and further work is needed to compare the additive effect of the two modalities.

'You're judged all the time!' Students' views on professionalism: a multicentre study.

OBJECTIVES: This study describes how medical students perceive professionalism and the context in which it is relevant to them. An understanding of how Phase 1 students perceive professionalism will help us to teach this subject more effectively. Phase 1 medical students are those in the first 2 years of a 5-year medical degree. METHODS: Seventy-two undergraduate students from two UK medical schools participated in 13 semi-structured focus groups. Focus groups, carried out until thematic saturation occurred, were recorded and transcribed verbatim. Data were analysed and coded using NVivo 8, using a grounded theory approach with constant comparison. RESULTS: From the analysis, seven themes regarding professionalism emerged: the context of professionalism; role-modelling; scrutiny of behaviour; professional identity; 'switching on' professionalism; leniency (for students with regard to professional standards), and sacrifice (of freedom as an individual). Students regarded professionalism as being relevant in three contexts: the clinical, the university and the virtual. Students called for leniency during their undergraduate course, opposing the guidance from Good Medical Practice. Unique findings were the impact of clothing and the online social networking site Facebook on professional behaviour and identity. Changing clothing was described as a mechanism by which students 'switch on' their professional identity. Students perceived society to be struggling with the distinction between doctors as individuals and professionals. This extended to the students' online identities on Facebook. Institutions' expectations of high standards of professionalism were associated with a feeling of sacrifice by students caused by the perception of constantly 'being watched'; this perception was coupled with resentment of this intrusion. Students described the significant impact that role-modelling had on their professional attitudes. CONCLUSIONS: This research offers valuable insight into how Phase 1 medical students construct their personal and professional identities in both the offline and online environments. Acknowledging these learning mechanisms will enhance the development of a genuinely student-focused professionalism curriculum.

Peer estimation of lack of professionalism correlates with low Conscientiousness Index scores.

CONTEXT: Measures of professionalism in undergraduate medical students are generally subjective in nature, and based on limited observations of behaviours in observed settings. We have previously described an objective scalar measure of conscientiousness over many occasions, and shown that it correlates with independent faculty estimates of students' professionalism. In this study we test the hypothesis that these measures of conscientiousness relate to independent peer estimates of professionalism, and explore the relationships between conscientiousness, and gender and educational background. METHODS: Medical students in Years 1 and 2 of an undergraduate programme were invited to estimate the professionalism of fellow students using a peer nomination approach. The correlation with the Conscientiousness Index (CI) for each student receiving nominations was explored statistically. Male and female students, from three educational backgrounds, were also compared on the basis of their CI scores. Developmental properties were considered by comparing Year 2 students' CI scores with their corresponding Year 1 performance. RESULTS: There was a statistically significant negative correlation between CI scores and nominations for lack of professionalism. No differences were observed between male and female students. There were occasional differences between students of different educational backgrounds, but the sample sizes of some groups were small and we would not wish to over-interpret these data. CONCLUSIONS: These results support the use of the CI as a scalar, objective potential measure of professionalism, although the observations require repetition elsewhere and over an extended period of time in order to determine the predictive value of this approach.

Naloxone does not inhibit the attenuation of the response to severe haemorrhage seen after simulated injury in the anaesthetized rat.

Severe haemorrhage leads to a reflex bradycardia and hypotension. This is thought to be protective, but is attenuated by both concomitant musculoskeletal injury and exogenous morphine. The aim of this study was to determine whether the injury-induced attenuation of the response to severe haemorrhage could be blocked by naloxone. Male Wistar rats, terminally anaesthetized with alphadolone/alphaxalone (19-20 mg kg(-1) h(-1)I.V.), were randomly allocated to one of four groups. In groups I and IV, haemorrhage was simple [40% of estimated total blood volume (BV)], while in groups II and III it was initiated 10 min after the onset of bilateral hindlimb ischaemia (a model of musculoskeletal injury). Groups I and II received 20 microl of 0.9% saline intracerebroventricularly (I.C.V.) immediately before haemorrhage, while groups III and IV received 20 microg of naloxone I.C.V., in the same volume. In group I, the bradycardia reached its peak after the loss of 32.8 +/- 0.3% BV (mean +/- S.E.M.). Blood pressure did not fall significantly until the loss of 15.0 +/- 3.0% BV. The response in group IV was not significantly different from group I. By contrast, the bradycardia was absent after similar blood losses in groups II and III, while hypotension was attenuated. These results indicate that naloxone, at a dose known to be effective in blocking mu-opioid receptors and preventing other aspects of the response to injury, does not prevent the injury-induced attenuation of the response to severe haemorrhage. Thus the attenuation of the response to blood loss by injury is unlikely to be mediated via the mu-opioid receptors.