How students and specialists appreciate the mini-clinical evaluation exercise (mini-CEX) in Indonesian clerkships.

BACKGROUND: Cultural differences might challenge the acceptance of the implementation of assessment formats that are developed in other countries. Acceptance of assessment formats is essential for its effectiveness; therefore, we explored the views of students and specialists on the practicality and impact on learning of these formats. This study was conducted to explore Indonesian students' and specialists' appreciation of the implementation of the Mini-Clinical Evaluation Exercise (Mini-CEX) in Indonesian clerkships. METHODS: This study was conducted at the Universitas Gadjah Mada, Indonesia. Participants were 52 students and 21 specialists in neurology and 78 students and 50 specialists in internal medicine. They were asked to complete a 19-item questionnaire that covered the characteristics of the mini-CEX such as its practicality, and the impact on learning and professional development. We used a Mann-Whitney U test to analyse the data. RESULTS: In total, 124 students (46 from neurology and 78 from internal medicine) and 38 specialists (13 from neurology and 25 from internal medicine) participated in this study. Students and specialists were positive about the practicality of the mini-CEX and the impact of this assessment format on learning and on professional development. The Mann-Whitney U test showed that there were no significant differences between students' and specialists' opinions on the mini-CEX, except for 2 items: specialists' appreciation of direct observation (mean rank = 93.16) was statistically significantly higher than students' appreciation of it (mean rank = 77.93; z = 2.065; p < 0.05), but students' appreciation of the item that students' past mini-CEX results affected their recent mini-CEX outcomes (mean rank = 85.29) was significantly higher than specialists' appreciation of it (mean rank = 69.12; z = 2140; p < 0.05). CONCLUSION: Students and specialists were positive about the mini-CEX in Indonesian clerkships, although it was developed and validated in another culture. We found only small differences between their appreciations, which could be explained by the patterns of specialist-student interaction in Indonesian culture as large power distance and low individualism country.

The effects of a non-cognitive versus cognitive admission procedure within cohorts in one medical school.

In medical school selection, non-cognitive performance in particular correlates with performance in clinical practice. It is arguable, therefore, that selection should focus on non-cognitive aspects despite the predictive value of prior cognitive performance for early medical school performance. The aim of this study at Radboud University Medical Center, the Netherlands, is to determine the effects of admitting students through an autonomous non-cognitive procedure on early medical school performance. We compared their performance to the performance of students selected through an autonomous cognitive selection procedure, enrolling in the Bachelor's curriculum simultaneously. 574 students (2013 and 2014 cohorts), admitted through non-cognitive selection (based on portfolio, CASPer and MMI, n = 135) or cognitive selection (curriculum sample selection, n = 439) were included in the study. We compared dropout rates, course credits and grades, using logistic and linear regression. The dropout rate was the highest in the non-cognitive selection group (p < 0.001). Students admitted through non-cognitive selection more often obtained the highest grade for the nursing attachment (p = 0.02) and had a higher mean grade for the practical clinical course in year 3 (p = .04). No differences in course grades were found. The results indicate that students perform best on the elements of the curriculum that are represented most strongly in the selection procedure they had participated in. We recommend the use of curriculum sample procedures, resembling the early medical school curriculum,-whether it has a more cognitive or a more non-cognitive focus-, to select the students who are likely to be successful in the subsequent curriculum.

Clinical workplace learning: perceived learning value of individual and group feedback in a collectivistic culture.

BACKGROUND: Feedback is essential for workplace learning. Most papers in this field concern individual feedback. In collectivistic cultures, however, group feedback is common educational practice. This study was conducted to investigate the perceived learning value and characteristics of individual and group feedback in a collectivistic culture. METHODS: During two weeks, on a daily basis, clerkship students (n = 215) from 12 clinical departments at Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia, recorded individual and group feedback moments by using a structured form: the providers, focus and perceived learning value of feedback. Data were analysed with logistic regression and multilevel techniques. RESULTS: Students reported 2687 group and 1535 individual feedback moments. Group feedback more often focused on history taking, clinical judgment, patient management, patient counselling, and professional behaviour (OR ranging from 1.232, p < .01, to 2.152, p < .001), but less often on physical examination (OR = .836, p < .01). Group feedback less often aimed at correcting performance deficiencies (OR = .523, p < .001) and more often at comparing performance to the standard (OR = 2.447, p < .001) and planning action to improve performance (OR = 1.759, p < .001). Group feedback was perceived as more valuable than individual feedback (M = 4.08 and 3.96, respectively, ß group = .065, SE = .026, p < .01). CONCLUSION: In collectivistic cultures, group feedback may add to the array of educational measures that optimize student learning. Congruence between culture and type of feedback may be important for the effectiveness of feedback.

Impact of vocational interests, previous academic experience, gender and age on Situational Judgement Test performance.

Situational Judgement Tests (SJTs) are increasingly implemented in medical school admissions. In this paper, we investigate the effects of vocational interests, previous academic experience, gender and age on SJT performance. The SJT was part of the selection process for the Bachelor's degree programme in Medicine at University of Groningen, the Netherlands. All applicants for the academic year 2015-2016 were included and had to choose between learning communities Global Health (n = 126), Sustainable Care (n = 149), Intramural Care (n = 225), or Molecular Medicine (n = 116). This choice was used as a proxy for vocational interest. In addition, all graduate-entry applicants for academic year 2015-2016 (n = 213) were included to examine the effect of previous academic experience on performance. We used MANCOVA analyses with Bonferroni post hoc multiple comparisons tests for applicant performance on a six-scenario SJT. The MANCOVA analyses showed that for all scenarios, the independent variables were significantly related to performance (Pillai's Trace: 0.02-0.47, p < .01). Vocational interest was related to performance on three scenarios (p < .01). Graduate-entry applicants outperformed all other groups on three scenarios (p < .01) and at least one other group on the other three scenarios (p < .01). Female applicants outperformed male applicants on three scenarios (p < .01) and age was positively related to performance on two scenarios (p < .05). A good fit between applicants' vocational interests and SJT scenario was related to better performance, as was previous academic experience. Gender and age were related to performance on SJT scenarios in different settings. Especially the first effect might be helpful in selecting appropriate candidates for areas of health care in which more professionals are needed.

The effect of curriculum sample selection for medical school.

In the Netherlands, students are admitted to medical school through (1) selection, (2) direct access by high pre-university Grade Point Average (pu-GPA), (3) lottery after being rejected in the selection procedure, or (4) lottery. At Radboud University Medical Center, 2010 was the first year we selected applicants. We designed a procedure based on tasks mimicking the reality of early medical school. Applicants took an online course followed by an on-site exam, resembling courses and exams in early medical school. Based on the exam scores, applicants were selected or rejected. The aim of our study is to determine whether curriculum sample selection explains performance in medical school and is preferable compared to selection based on performance in secondary school. We gathered data on the performance of students of three consecutive cohorts (2010-2012, N = 954). We compared medical school performance (course credits and grade points) of selected students to the three groups admitted in other ways, especially lottery admissions. In regression analyses, we controlled for out of context cognitive performance by adjusting for pu-GPA. Selection-admitted students outperformed lottery-admitted students on most outcome measures, unadjusted as well as adjusted for pu-GPA (p ≤ 0.05). They had higher grade points than non-selected lottery students, both unadjusted and adjusted for pu-GPA (p ≤ 0.025). Adjusted for pu-GPA, selection-admitted students and high-pu-GPA students performed equally. We recommend this selection procedure as it adds to secondary school cognitive performance for the general population of students, is efficient for large numbers of applicants and not labour-intensive.

Participation and selection effects of a voluntary selection process.

Many different medical school selection processes are used worldwide. In this paper, we examine the effect of (1) participation, and (2) selection in a voluntary selection process on study performance. We included data from two cohorts of medical students admitted to Erasmus MC, Rotterdam and VUmc, Amsterdam, The Netherlands and compared them to previously published data from Groningen medical school, The Netherlands. All included students were admitted based on either (1) a top pre-university grade point average, or (2) a voluntary selection process, or (3) weighted lottery. We distinguished between lottery-admitted students who had participated in the voluntary selection process and had been rejected, and lottery-admitted students who had not participated. Knowledge test scores, study progress, and professionalism scores were examined using ANCOVA modelling, logistic regression, and Bonferroni post hoc multiple-comparison tests, controlling for gender and cohort. For written test grades, results showed a participation effect at Groningen medical school and Erasmus MC (p < 0.001), and a selection effect at VUmc (p < 0.05). For obtained course credits, results showed a participation effect at all universities (p < 0.01) and a selection effect at Groningen medical school (p < 0.005). At Groningen medical school, a participation effect seemed apparent in on time first-year completion (p < 0.05). Earlier reported selection and participation effects in professionalism scores at Groningen medical school were not apparent at VUmc. Top pre-university students performed well on all outcome measures. For both the participation effect and the selection effect, results differed between universities. Institutional differences in curricula and in the design of the selection process seem to mediate relations between the different admissions processes and performance. Further research is needed for a deeper understanding of the influence of institutional differences on selection outcomes.

Comparison of formula and number-right scoring in undergraduate medical training: a Rasch model analysis.

BACKGROUND: Progress testing is an assessment tool used to periodically assess all students at the end-of-curriculum level. Because students cannot know everything, it is important that they recognize their lack of knowledge. For that reason, the formula-scoring method has usually been used. However, where partial knowledge needs to be taken into account, the number-right scoring method is used. Research comparing both methods has yielded conflicting results. As far as we know, in all these studies, Classical Test Theory or Generalizability Theory was used to analyze the data. In contrast to these studies, we will explore the use of the Rasch model to compare both methods. METHODS: A 2 × 2 crossover design was used in a study where 298 students from four medical schools participated. A sample of 200 previously used questions from the progress tests was selected. The data were analyzed using the Rasch model, which provides fit parameters, reliability coefficients, and response option analysis. RESULTS: The fit parameters were in the optimal interval ranging from 0.50 to 1.50, and the means were around 1.00. The person and item reliability coefficients were higher in the number-right condition than in the formula-scoring condition. The response option analysis showed that the majority of dysfunctional items emerged in the formula-scoring condition. CONCLUSIONS: The findings of this study support the use of number-right scoring over formula scoring. Rasch model analyses showed that tests with number-right scoring have better psychometric properties than formula scoring. However, choosing the appropriate scoring method should depend not only on psychometric properties but also on self-directed test-taking strategies and metacognitive skills.

Physician job satisfaction related to actual and preferred job size.

BACKGROUND: Job satisfaction is essential for physicians' well-being and patient care. The work ethic of long days and hard work that has been advocated for decades is acknowledged as a threat for physicians' job satisfaction, well-being, and patient safety. Our aim was to determine the actual and preferred job size of physicians and to investigate how these and the differences between them influence physicians' job satisfaction. METHOD: Data were retrieved from a larger, longitudinal study among physicians starting medical training at Groningen University in 1982/83/92/93 (N = 597). Data from 506 participants (85%) were available for this study. We used regression analysis to investigate the influence of job size on physicians' job satisfaction (13 aspects) and ANOVA to examine differences in job satisfaction between physicians wishing to retain, reduce or increase job size. RESULTS: The majority of the respondents (57%) had an actual job size less than 1.0 FTE. More than 80% of all respondents preferred not to work full-time in the future. Respondents' average actual and preferred job sizes were .85 FTE and .81 FTE, respectively. On average, respondents who wished to work less (35% of respondents) preferred a job size reduction of 0.18 FTE and those who wished to work more (12%) preferred an increase in job size of 0.16 FTE. Job size influenced satisfaction with balance work-private hours most (ß = -.351). Physicians who preferred larger job sizes were - compared to the other groups of physicians - least satisfied with professional accomplishments. CONCLUSIONS: A considerable group of physicians reported a gap between actual and preferred job size. Realizing physicians' preferences as to job size will hardly affect total workforce, but may greatly benefit individual physicians as well as their patients and society. Therefore, it seems time for a shift in work ethic.

Influence of feedback characteristics on perceived learning value of feedback in clerkships: does culture matter?

BACKGROUND: Various feedback characteristics have been suggested to positively influence student learning. It is not clear how these feedback characteristics contribute to students' perceived learning value of feedback in cultures classified low on the cultural dimension of individualism and high on power distance. This study was conducted to validate the influence of five feedback characteristics on students' perceived learning value of feedback in an Indonesian clerkship context. METHODS: We asked clerks in Neurology (n = 169) and Internal Medicine (n = 132) to assess on a 5-point Likert scale the learning value of the feedback they received. We asked them to record whether the feedback provider (1) informed the student what went well, (2) mentioned which aspects of performance needed improvement, (3) compared the student's performance to a standard, (4) further explained or demonstrated the correct performance, and (5) prepared an action plan with the student to improve performance. Data were analyzed using multilevel regression. RESULTS: A total of 250 students participated in this study, 131 from Internal Medicine (response rate 99%) and 119 from Neurology (response rate 70%). Of these participants, 225 respondents (44% males, 56% females) completed the form and reported 889 feedback moments. Students perceived feedback as more valuable when the feedback provider mentioned their weaknesses (ß = 0.153, p < 0.01), compared their performance to a standard (ß = 0.159, p < 0.01), explained or demonstrated the correct performance (ß = 0.324, p < 0.001) and prepared an action plan with the student (ß =0.496, p < 0.001). Appraisal of good performance did not influence the perceived learning value of feedback. No gender differences were found for perceived learning value. CONCLUSIONS: In Indonesia, we could validate four out of the five characteristics for effective feedback. We argue that our findings relate to culture, in particular to the levels of individualism and power distance. The recognized characteristics of what constitutes effective feedback should be validated across cultures.

What supervisors say in their feedback: construction of CanMEDS roles in workplace settings.

The CanMEDS framework has been widely adopted in residency education and feedback processes are guided by it. It is, however, only one of many influences on what is actually discussed in feedback. The sociohistorical culture of medicine and individual supervisors' contexts, experiences and beliefs are also influential. Our aim was to find how CanMEDS roles are constructed in feedback in a postgraduate curriculum-in-action. We applied a set of discourse analytic tools to written feedback from 591 feedback forms from 7 hospitals, including 3150 feedback comments in which 126 supervisors provided feedback to 120 residents after observing their performance in authentic settings. The role of Collaborator was constructed in two different ways: a cooperative discourse of equality with other workers and patients; and a discourse, which gave residents positions of power-delegating, asserting and 'taking a firm stance'. Efficiency-being fast and to the point emerged as an important attribute of physicians. Patients were seldom part of the discourses and, when they were, they were constructed as objects of communication and collaboration rather than partners. Although some of the discourses are in line with what might be expected, others were in striking contrast to the spirit of CanMEDS. This study's findings suggest that it takes more than a competency framework, evaluation instruments, and supervisor training to change the culture of workplaces. The impact on residents of training in such demanding, efficiency-focused clinical environments is an important topic for future research.

Weak self-directed learning skills hamper performance in cumulative assessment.

BACKGROUND: Self-regulated learning is an important determinant of academic performance. Previous research has shown that cumulative assessment encourages students to work harder and improve their results. However, not all students seem to respond as intended. We investigated the influence of students' behavioral traits on their responsiveness to a cumulative assessment strategy. METHOD: The cumulative test results of a third-year integrated ten-week course unit were analyzed. The test was divided into three parts delivered at 4, 8 and 10 weeks. Low starters (below median) with low or high improvement (below or above the median) were identified and compared regarding their behavioral traits (assessed with the Temperament and Character Inventory questionnaire). RESULTS: A total of 295 students filled out the questionnaire. A percentage of 70% of the students below the median on the first two test parts improved during the final part. Students who were less responsive to improve their test results, scored low only on the TCI scale "self directedness" (t = 2.49; p = 0.011). CONCLUSION: Behavioral traits appear to influence student reactions to feedback on test results, with students with low self-directedness scores being particularly at risk. They can thus be identified and should receive special attention from student counselors.

A feedback system in residency to evaluate CanMEDS roles and provide high-quality feedback: Exploring its application.

INTRODUCTION: Residents benefit from regular, high quality feedback on all CanMEDS roles during their training. However, feedback mostly concerns Medical Expert, leaving the other roles behind. A feedback system was developed to guide supervisors in providing feedback on CanMEDS roles. We analyzed whether feedback was provided on the intended roles and explored differences in quality of written feedback. METHODS: In the feedback system, CanMEDS roles were assigned to five authentic situations: Patient Encounter, Morning Report, On-call, CAT, and Oral Presentation. Quality of feedback was operationalized as specificity and inclusion of strengths and improvement points. Differences in specificity between roles were tested with Mann-Whitney U tests with a Bonferroni correction (α = 0.003). RESULTS: Supervisors (n = 126) provided residents (n = 120) with feedback (591 times). Feedback was provided on the intended roles, most frequently on Scholar (78%) and Communicator (71%); least on Manager (47%), and Collaborator (56%). Strengths (78%) were mentioned more frequently than improvement points (52%), which were lacking in 40% of the feedback on Manager, Professional, and Collaborator. Feedback on Scholar was more frequently (p = 0.000) and on Reflective Professional was less frequently (p = 0.003) specific. DISCUSSION AND CONCLUSION: Assigning roles to authentic situations guides supervisors in providing feedback on different CanMEDS roles. We recommend additional supervisor training on how to observe and evaluate the roles.

Supervisor leadership in relation to resident job satisfaction.

BACKGROUND: Research from outside the medical field shows that leadership behaviours influence job satisfaction. Whether the same is true for the medical training setting needs to be explored. The aim of this study was to investigate the influence of residents' overall appreciation of their supervisor's leadership and observation of specific supervisor leadership behaviours on job satisfaction. METHODS: We invited residents (N = 117) to rate how often they observed certain task and relation-oriented leadership behaviours in their supervisor and overall appreciation of their supervisor's leadership. Furthermore, they rated their satisfaction with 13 different aspects of their jobs on a 10-point scale. Using exploratory factor analysis we identified four factors covering different types of job satisfaction aspects: personal growth, autonomy, affective, and instrumental job satisfaction aspects. Influence of overall appreciation for supervisor leadership and observation of certain leadership behaviours on these job satisfaction factors were analysed using multiple regression analyses. RESULTS: The affective aspects of job satisfaction were positively influenced by overall appreciation of leadership (B = 0.792, p = 0.017), observation of specific instructions (B = 0.972, p = 0.008) and two-way communication (B = 1.376, p = 0.008) and negatively by mutual decision-making (B = -1.285, p = 0.007). No effects were found for the other three factors of job satisfaction. CONCLUSIONS: We recommend that supervisors become more aware of whether and how their behaviours influence residents' job satisfaction. Especially providing specific instructions and using two-way communication seem important to help residents deal with their insecurities and to offer them support.

Predicting performance: relative importance of students' background and past performance.

CONTEXT: Despite evidence for the predictive value of both pre-admission characteristics and past performance at medical school, their relative contribution to predicting medical school performance has not been thoroughly investigated. OBJECTIVES: This study was designed to determine the relative importance of pre-admission characteristics and past performance in medical school in predicting student performance in pre-clinical and clinical training. METHODS: This longitudinal prospective study followed six cohorts of students admitted to a Dutch, 6-year, undergraduate medical course during 2002-2007 (n = 2357). Four prediction models were developed using multivariate logistic regression analysis. Main outcome measures were 'Year 1 course completion within 1 year' (models 1a, 1b), 'Pre-clinical course completion within 4 years' (model 2) and 'Achievement of at least three of five clerkship grades of ≥ 8.0' (model 3). Pre-admission characteristics (models 1a, 1b, 2, 3) and past performance at medical school (models 1b, 2, 3) were included as predictor variables. RESULTS: In model 1a - including pre-admission characteristics only - the strongest predictor for Year 1 course completion was pre-university grade point average (GPA). Success factors were 'selected by admission testing' and 'age > 21 years'; risk factors were 'Surinamese/Antillean background', 'foreign pre-university degree', 'doctor parent' and male gender. In model 1b, number of attempts and GPA at 4 months were the strongest predictors for Year 1 course completion, and male gender remained a risk factor. Year 1 GPA was the strongest predictor for pre-clinical course completion, whereas being male or aged 19-21 years were risk factors. Pre-clinical course GPA positively predicted clinical performance, whereas being non-Dutch or a first-generation university student were important risk factors for lower clinical grades. Nagelkerke's R(2) ranged from 0.16 to 0.62. CONCLUSIONS: This study not only confirms the importance of past performance as a predictor of future performance in pre-clinical training, but also reveals the importance of a student's background as a predictor in clinical training. These findings have important practical implications for selection and support during medical school.

Cumulative versus end-of-course assessment: effects on self-study time and test performance.

CONTEXT: Students tend to postpone preparation for a test until the test is imminent, which raises various risks associated with 'cramming' behaviours, including that for suboptimal learning. Cumulative assessment utilises spaced testing to stimulate students to study more frequently and to prevent procrastination. This randomised controlled study investigated how cumulative assessment affects time spent on self-study and test performance compared with end-of-course assessment. METHODS: A total of 78 undergraduate medical students in a Year 2 pre-clinical course were randomly assigned to either of two conditions. Students in the cumulative assessment condition were assessed in weeks 4, 8 and 10. Students in the end-of-course assessment condition were assessed in week 10 only. Each week, students reported the number of hours they spent on self-study. RESULTS: Students in the cumulative assessment condition (n = 25) spent significantly more time on self-study than students in the end-of-course assessment condition (n = 37) in all weeks of the course except weeks 5, 9 and 10. Overall, the cumulative assessment group spent 69 hours more on self-study during the course than did the control group, although the control group spent 7 hours more in studying during the final week of the course than did the cumulative assessment group. Students in the cumulative assessment condition scored slightly higher on questions concerning the content of the last part of the course. CONCLUSIONS: Cumulative assessment encourages students to distribute their learning activities over a course, which leaves them more opportunity to study the content of the last part of the course prior to the final examination. There was no evidence for a short-term effect of cumulative assessment on overall knowledge gain. We hypothesise that larger positive effects might be found if retention were to be measured in the long term.

Student distress in clinical workplace learning: differences in social comparison behaviours.

In medical education, student distress is known to hamper learning and professional development. To address this problem, recent studies aimed at helping students cope with stressful situations. Undergraduate students in clinical practice frequently use experiences of surrounding peers to estimate their abilities to master such challenging situations. This use of the experiences of others, known as social comparison, may affect student distress both positively and negatively. To find characteristics of a beneficial use of social comparison, we examined differences in comparison behaviours between students expressing low and high levels of distress. The participants in our study, response rate 93% (N = 301/321), were all medical students in their first year in clinical practice. They completed the General Health Questionnaire (GHQ-12) to measure distress, and three separate questionnaires to measure: (1) orientation to comparison, (2) motive for comparison, and (3) interpretation of comparison. Differences were analysed using multivariate analysis of variance. Although all students were oriented towards social comparison, the analyses showed that this orientation was less apparent among low-distress students. Besides, the low-distress students were less inclined to use motives indicative for comparisons with peers perceived as performing worse and were less negative in the interpretations of their comparisons. As social comparison is frequently used among all students, we recommend to make them aware of their comparison behaviours and inform them about the pros and cons of the distinguished aspects of the comparison process.

Leadership in the clinical workplace: what residents report to observe and supervisors report to display: an exploratory questionnaire study.

BACKGROUND: Within the current health care system, leadership is considered important for physicians. leadership is mostly self-taught, through observing and practicing. Does the practice environment offer residents enough opportunities to observe the supervisor leadership behaviours they have to learn? In the current study we investigate which leadership behaviours residents observe throughout their training, which behaviours supervisors report to display and whether residents and supervisors have a need for more formal training. METHODS: We performed two questionnaire studies. Study 1: Residents (n = 117) answered questions about the extent to which they observed four basic and observable Situational Leadership behaviours in their supervisors. Study 2: Supervisors (n = 201) answered questions about the extent to which they perceived to display these Situational Leadership behaviours in medical practice. We asked both groups of participants whether they experienced a need for formal leadership training. RESULTS: One-third of the residents did not observe the four basic Situational Leadership behaviours. The same pattern was found among starting, intermediate and experienced residents. Moreover, not all supervisors showed these 4 leadership behaviours. Both supervisors and residents expressed a need for formal leadership training. CONCLUSION: Both findings together suggest that current practice does not offer residents enough opportunities to acquire these leadership behaviours by solely observing their supervisors. Moreover, residents and supervisors both express a need for more formal leadership training. More explicit attention should be paid to leadership development, for example by providing formal leadership training for supervisors and residents.

Selection and study performance: comparing three admission processes within one medical school.

OBJECTIVES: This study was conducted to: (i) analyse whether students admitted to one medical school based on top pre-university grades, a voluntary multifaceted selection process, or lottery, respectively, differed in study performance; (ii) examine whether students who were accepted in the multifaceted selection process outperformed their rejected peers, and (iii) analyse whether participation in the multifaceted selection procedure was related to performance. METHODS: We examined knowledge test and professionalism scores, study progress and dropout in three cohorts of medical students admitted to the University of Groningen, the Netherlands in 2009, 2010 and 2011 (n = 1055). We divided the lottery-admitted group into, respectively, students who had not participated and students who had been rejected in the multifaceted selection process. We used ancova modelling, logistic regression and Bonferroni post hoc multiple-comparison tests and controlled for gender and cohort. RESULTS: The top pre-university grade group achieved higher knowledge test scores and more Year 1 course credits than all other groups (p < 0.05). This group received the highest possible professionalism score more often than the lottery-admitted group that had not participated in the multifaceted selection process (p < 0.05). The group of students accepted in the multifaceted selection process obtained higher written test scores than the lottery-admitted group that had not participated (p < 0.05) and achieved the highest possible professionalism score more often than both lottery-admitted groups. The lottery-admitted group that had not participated in the multifaceted selection process earned fewer Year 1 and 2 course credits than all other groups (p < 0.05). Dropout rates differed among the groups (p < 0.05), but correction for multiple comparisons rendered all pairwise differences non-significant. CONCLUSIONS: A top pre-university grade point average was the best predictor of performance. For so-called non-academic performance, the multifaceted selection process was efficient in identifying applicants with suitable skills. Participation in the multifaceted selection procedure seems to be predictive of higher performance. Further research is needed to assess whether our results are generalisable to other medical schools.

The influence of achievement before, during and after medical school on physician job satisfaction.

In this longitudinal study, we investigated the relationship between physicians' prior achievements (before, during and after medical school) and job satisfaction, and tested the two lines of reasoning that prior achievements influence job satisfaction positively or negatively, respectively. The participants were graduates who started their medical training in 1982 (n = 147), 1983 (n = 154), 1992 (n = 143) and 1993 (n = 153). We operationalised job satisfaction as satisfaction (on a 10-point scale) with 13 cognitive, affective and instrumental aspects of the participants' jobs. The measures of achievement before, during and after medical school included pre-university grade point average, study progress and a residency position in the specialty of first choice, respectively. We included the effect of curriculum type (problem-based learning versus traditional), gender and years of experience as moderator variables. Higher achievers before and during medical school were more satisfied about their income (ß = .152, p < .01 and ß = .149, p < .05), but less satisfied with their opportunities for personal development (ß = -.159, p < .05). High achievers after medical school were more satisfied with professional accomplishments (ß = .095, p < .05), with appreciation from support personnel (ß = .154, p < .01) and from patients (ß = .120, p < .05). Effect sizes were small. Prior achievements influenced job satisfaction. The direction of the influences depended on the job satisfaction aspect in question, which indicates that it is important to distinguish between aspects of job satisfaction. To optimize job satisfaction of high achievers, it is important for graduates to obtain their preferred specialty. Furthermore, it is vital to provide them with enough opportunities for further development.

Meeting international standards: a cultural approach in implementing the mini-CEX effectively in Indonesian clerkships.

UNLABELLED: Abstract Background: Medical schools all over the world try to adapt their programs to meet international standards. However, local culture might hamper innovation attempts. AIMS: To describe challenges in implementing the mini-CEX in Indonesia and investigate its effect on students' clinical competence. METHODS: The study was conducted in the Internal Medicine and Neurology departments of the Universitas Gadjah Mada, Indonesia. Implementing the mini-CEX into the existing curriculum, while taking the Indonesian culture into account, implied a shift from group to individual feedback. We compared students' final clinical competence before (Internal Medicine n = 122, Neurology n = 183) and after (n = 183 and 186, respectively) the implementation of the mini-CEX, using a modified Objective Structured Long Examination Record (OSLER). The Mann-Whitney test was used to analyze the data. RESULTS: We took power distance and individualism into account to facilitate the implementation process. After implementing the mini-CEX, the OSLER results were significant higher in Internal Medicine (p < 0.05). However, no differences were found in Neurology. CONCLUSION: By managing the innovation process carefully and taking culture and local context into account, the mini-CEX can be implemented without changing the underlying concept. The shift from group to individual feedback seems to have a positive effect on student learning.