Longitudinal integrated clerkships.

There is increased interest in longitudinal integrated clerkships (LICs) due to mounting evidence of positive outcomes for students, patients and supervising clinicians. Emphasizing continuity as the organizing principle of an LIC, this article reviews evidence and presents perspectives of LIC participants concerning continuity of care, supervision and curriculum, and continuity with peers and systems of care. It also offers advice on implementing or evaluating existing LIC programs.

Using a framework to implement large-scale innovation in medical education with the intent of achieving sustainability.

BACKGROUND: Particularly when undertaken on a large scale, implementing innovation in higher education poses many challenges. Sustaining the innovation requires early adoption of a coherent implementation strategy. Using an example from clinical education, this article describes a process used to implement a large-scale innovation with the intent of achieving sustainability. Desire to improve the effectiveness of undergraduate medical education has led to growing support for a longitudinal integrated clerkship (LIC) model. This involves a move away from the traditional clerkship of 'block rotations' with frequent changes in disciplines, to a focus upon clerkships with longer duration and opportunity for students to build sustained relationships with supervisors, mentors, colleagues and patients. A growing number of medical schools have adopted the LIC model for a small percentage of their students. At a time when increasing medical school numbers and class sizes are leading to competition for clinical supervisors it is however a daunting challenge to provide a longitudinal clerkship for an entire medical school class. This challenge is presented to illustrate the strategy used to implement sustainable large scale innovation. WHAT WAS DONE: A strategy to implement and build a sustainable longitudinal integrated community-based clerkship experience for all students was derived from a framework arising from Roberto and Levesque's research in business. The framework's four core processes: chartering, learning, mobilising and realigning, provided guidance in preparing and rolling out the 'whole of class' innovation. DISCUSSION: Roberto and Levesque's framework proved useful for identifying the foundations of the implementation strategy, with special emphasis on the relationship building required to implement such an ambitious initiative. Although this was innovation in a new School it required change within the school, wider university and health community. Challenges encountered included some resistance to moving away from traditional hospital-centred education, initial student concern, resource limitations, workforce shortage and potential burnout of the innovators. Large-scale innovations in medical education may productively draw upon research from other disciplines for guidance on how to lay the foundations for successfully achieving sustainability.

Are rural placements positively associated with rural intentions in medical graduates?

CONTEXT: Medical school curricula remain one of the key levers in increasing the future supply of rural doctors. Data from Australia and overseas have suggested exposure to rural practice via rural placements during basic medical training is positively associated with graduates becoming rural doctors. However, previous studies have suffered from serious methodological limitations. OBJECTIVES: This study sought to determine whether rural clinical placements are associated with a higher proportion of graduating students planning rural careers and to explore associations with timing, duration and location of placements. METHODS: Data were obtained from the Medical Schools Outcomes Database and Longitudinal Tracking Project, which is a longitudinal study with a high response rate that prospectively collects data, including practice location intention, from all Australian medical schools. Using logistic regression analysis, the association between placements and rural career intention was assessed, controlling for a number of demographic and contextual variables. RESULTS: The association between rural/remote placements later in the programme and rural practice intention was strongly positive whether viewed as simple occurrence or as duration, in contrast to later urban placements, which were strongly negative. A longer duration of placement enhanced the associations reported. Non-metropolitan medical schools were also associated with higher odds of intention to take up rural practice. However, the association with rural placements was overshadowed by the strong positive associations with rural background of students and their stated intention to become a rural doctor at the start of their studies. CONCLUSIONS: Exposure to rural practice during basic medical training, and the location and curriculum focus of a medical school are confirmed as factors that are positively associated with students' intention to become rural doctors after graduation. However, rural origin and the early intentions at the start of their medical training are better predictors of expressed intention to take up rural practice than rural clinical placements.

Empathy is related to clinical competence in medical care.

OBJECTIVES: Most medical schools focus upon aspects of interpersonal functioning such as empathy in the doctor-patient relationship with the aim of training clinically competent doctors. This study investigated the relationship between empathy and clinical competence among medical students. METHODS: Fifty-seven medical students participated in the study. Clinical competence was assessed in an objective structured clinical examination (OSCE). Empathy was rated by an independent observer of the clinical interaction in OSCE stations. In addition, empathy was self-rated using the Jefferson Scale of Physician Empathy-Student Version. RESULTS: Observed behaviour indicative of empathy, as rated objectively by an independent observer, was strongly associated with clinical competence. The strong association between the behavioural manifestation of empathy and clinical competence was evident across a range of medical conditions and types of consultation. In addition, observable empathy was strongly associated with patients' ratings of the students' performances. Self-rated empathy, however, was not associated with clinical competence. Significant differences in mean total competence scores were noted between students low in observed empathy (mean ± standard deviation [SD]: 165.86 ± 12.92) and students high in observed empathy (mean ± SD: 190.35 ± 14.00) (t[55] = 6.28, p = 0.000, α ≤ 0.01). CONCLUSIONS: In medical education, strategies that enhance the behavioural expression of empathy (or at least retard its decay) could help to make medical students appear to be more clinically competent to both examiners and patients. However, if medical students' internal emotions are found to be discrepant with their behaviour, these findings will raise difficult questions regarding the fundamental nature of genuine empathy and alert us to the possibility that medical students may learn that it pays to subscribe to the view that if a person does not feel empathy, he or she can fake it.

Medical student characteristics associated with time in study: is spending more time always a good thing?

BACKGROUND: Time in study may reflect motivation, but may also reflect inefficient study habits. PURPOSE: To determine how time in study relates to motivation and study approaches. METHODS: A total of 173 fourth- and fifth-year students in a six-year curriculum completed diaries over seven consecutive days. Time studying was correlated with motivation and approaches to study. RESULTS: Time in study correlated with achieving motive, achieving strategy, deep strategy, motivation and planning/organisation. Deep motive correlated with time on assignments. Students who were less certain they wanted to work as a doctor undertook less study activity and spent less time with patients. Students who lacked confidence they would make a good doctor spent more time in non-timetabled discretionary study but also spent less time with patients. CONCLUSION: A desire to achieve, certainty of career choice and lack of confidence are associated with time in study. Unconfident students divert their time away from patients.

Epidemiology of pain in New Zealand.

Information on the prevalence of pain in the general population has relevance for the allocation of health services and for understanding of chronic pain. In 1986 a sample of 1498 adults were interviewed using the Diagnostic Interview Schedule. Questions on pain were taken from the somatisation section of the interview schedule. These responses were used to determine the lifetime prevalence of pain in the urban population of New Zealand. The majority of subjects reported more than one life disrupting experience of pain. Pain was most common in the joints, back, head and abdomen. Women reported more pain than men. In general the prevalence of pain increased with age, however this was not true for headaches and abdominal pain. Most subjects related their pain symptoms to a physical cause.

Early access and help seeking: practice implications and new initiatives.

AIM: Seeking appropriate help for early signs and symptoms of psychological distress can reduce the long-term impact of many mental disorders. This article describes practice implications and new initiatives for promoting early access and help-seeking among young people. METHODS: Relevant help-seeking research is reviewed, and prominent help-seeking barriers are discussed. RESULTS: Prominent barriers for young people include: incomplete mental health and emotional literacy, beliefs about having little need for help versus having a need for autonomy, and the process of help-negation for different symptoms of psychological distress. CONCLUSIONS: To improve early access to appropriate help and mental health services, barriers that can be reduced, and in particular, psychological distress symptoms that promote the help-negation process, must be reduced as soon as they can be. Strategies that can be used by clinicians, parents and others, including young people, to encourage appropriate help-seeking are provided. Examples of how these strategies are implemented in several innovative programs and approaches are discussed.

What is the educational impact of standards-based assessment in a medical degree?

CONTEXT: Many medical courses use standards-based assessment, usually reported by a restricted range of categories, but there is little evidence of its educational impact. This study aimed to evaluate the impact on medical student learning of changing to standards-based assessments reported by distinction, pass or fail. METHODS: We carried out a prospectively planned before-and-after study within an undergraduate medical course using a questionnaire to compare motivation and approaches to the study, and a diary to compare the number of hours spent studying. RESULTS: Questionnaire response rates were 607/752 (81%) before the change and 651/780 (83%) afterwards. Daily diary response rates were 1074/1478 (73%) before, and 1304/1844 (71%) after the change. Deep motive declined with class year during norm-referenced assessments but not with standards-based assessment (r = - 0.11 versus 0.01; P < 0.02). Deep strategy increased significantly under standards-based assessments in students in Years 2 and 3 (mean difference 0.64 [0.08-1.2]; P < 0.05) and Year 6 (mean difference 2.0 [0.03-3.9]; P < 0.05). Competitiveness scores declined as students progressed through the course in both cohorts. Students identified themselves as feeling more like a doctor after the change to standards-based assessments. Time spent studying was largely unchanged but the proportions of wanted discretionary study increased from 64% to 71% for students in Years 2 and 3, and from 65% to 70% for students in Years 4 and 5. CONCLUSIONS: The changes were associated with beneficial effects on deep motive, deep strategy, professional identify and intrinsically motivated study. There were no changes in competitiveness and minimal changes in amount of time spent studying.

Psychological health of men with partners who have post-partum depression.

OBJECTIVE: To compare the psychological health of men with partners who have post-partum depression (PPD; index group) with that of men with partners without PPD (comparison group). METHOD: Using a cross-sectional survey, psychological symptoms and disturbances of index group men (n = 58) and comparison group men (n = 116) were compared. Validated self-report measures were used to assess five key areas of mental health: depression, anxiety, non-specific psychological impairment, aggression and alcohol use. RESULTS: Index group men had more symptoms of depression, aggression and non-specific psychological impairment, and had higher rates of depressive disorder, non-specific psychological problems and problem fatigue than comparison group men. Index group men were also more likely to have three or more comorbid psychological disturbances. There was no difference between the groups on measures of anxiety and alcohol use. CONCLUSIONS: Although many men in the postnatal period experience a variety of mental health problems, those who have a partner with PPD are themselves at increased risk for experiencing psychological symptoms and disturbances. Differentiation of psychological syndromes is important; higher rates of depressive disorder, non-specific psychological problems and problem fatigue were found, but rates of anxiety disorder and hazardous alcohol use did not differ between the groups. More attention from health professionals to men's mental health in the postnatal period may be beneficial to the entire family system.

Using a diary to quantify learning activities.

BACKGROUND: Diaries of actual learning activities can fill the gap between the planned curriculum and students' opinions and outcomes. We report the development and validity of such a method, estimate sources of variation and model sampling strategies to determine efficient ways to obtain information about a curriculum or about individual students. METHODS: Following development and piloting, the diary was administered to fourth- and fifth-year medical students. Each student was asked to complete a diary on 3 randomly selected days of the academic year. Sources of variance and generalisability were determined using variance components analysis. Validity was explored by comparing activities with what is known about the curriculum, assessment, timetables and the 2 classes of students. RESULTS: Response rate was 83% (287/345). Learning activities varied as expected with timing of assessments, and on weekdays compared with weekends. For most activities, 14 days per student would be needed to obtain generalisable information about an individual student. The variation between days is greater than the variation between students, meaning that sampling for information on a curriculum should include all students and all days of the year but the number of diaries per student could be kept low depending on the desired power to detect any differences. CONCLUSION: Such an evaluation method is feasible and can provide reliable and valid information about study activities. Reasons for good compliance are discussed. Sampling strategies should be tailored to the purpose of the study.

Are differences between graduates and undergraduates in a medical course due to age or prior degree?

BACKGROUND: The number of medical programmes targeted at graduates is increasing and there are reports of beneficial outcomes. However, many new graduate medical schools have simultaneously changed their admission criteria and curricula. This study aimed to determine whether there were differences between graduates and undergraduates on the same medical course and to establish which differences might be due to having a prior degree, the course itself or age at entry to medical school. METHODS: A questionnaire-based survey was administered to all students in Years 2-5. It included the Study Process Questionnaire, the Achievement Motivation Profile and Likert scale questions on career. RESULTS: Questionnaires were completed by 587 students (response rate 80.3%), of whom 143 had a prior degree. Whilst having a prior degree was associated with many outcomes, for most this disappeared, and the overall predictive ability of the model improved when age was included. Age at entry to medical school brought certainty and motivation about career choice, a prior degree had some effect on approaches to studying and co-operativeness, while the course itself had effects on most outcomes, some of which were positive and some negative. CONCLUSION: Graduates bring a distinct quality to a course but many of these relate to a student's age. Older age at entry may be more important than having a prior degree.