Medical student learner neglect in the clinical learning environment: Applying Glaser's theoretical model.

INTRODUCTION: Learner neglect is a relatively new concept in education, and no suitable framework for its exploration has been devised. The aim of this study was to determine whether an existing framework, Glaser's framework of child neglect, could be applied to learner neglect in clinical learning environments. This was a retrospective analysis of data obtained as part of a related study. METHOD: Six focus groups were conducted with medical students in their early clinical years to explore their views of what experiences in medical education were challenging and why they presented a challenge. The transcript data were analysed using inductive content analysis, within an interpretivist approach in the development of categories. The identified categories were cross referenced with Glaser's framework categories replacing the carer with the teacher and the child with the learner. RESULTS: Glaser's classifications of teacher (parent) behaviours were all identified in the negative aspects of medical learner clinical education including emotional unavailability/unresponsiveness, acting in a hostile manner, inappropriate inconsistent developmental interaction, failure to recognise individuality and failure to promote social adaption. Physical unavailability was identified as an additional category and is included in our proposed framework of learner neglect. DISCUSSION: Adapting Glaser's framework was useful in considering learner neglect. Medical schools have a role in ensuring learning experiences are positive across contexts and to make explicit to teachers any behaviours that may appear as learner neglect. Applying this framework has the potential to make more explicit any subtle undermining teacher behaviours. Once explicit, there is a greater likelihood that behaviours may be reappraised both by the teacher and learner and modified to promote a more effective clinical learning experience.

Challenging feedback myths: Values, learner involvement and promoting effects beyond the immediate task.

CONTEXT: Research suggests that feedback in the health professions is less useful than we would like. In this paper, we argue that feedback has become reliant on myths that perpetuate unproductive rituals. Feedback often resembles a discrete episode of an educator "telling," rather than an active and iterative involvement of the learner in a future-facing process. With this orientation towards past events, it is not surprising that learners become defensive or disengaged when they are reminded of their deficits. METHODS: We tackle three myths of feedback: (a) feedback needs praise-criticism balancing rules; (b) feedback is a skill residing within the teacher; and (c) feedback is an input only. For each myth we provide a reframing with supporting examples from the literature. CONCLUSIONS: Equipping learners to engage in feedback processes may reduce the emotional burden on both parties, rendering techniques such as the feedback sandwich redundant. We also highlight the benefits for learners and teachers of conceptualising feedback as a relational activity, and of tracing the effects of information exchanges. These effects may be immediate or latent, and may manifest in different forms such as changes in learner evaluative judgement or professional identity.

The stress paradox: how stress can be good for learning.

CONTEXT: This article explores the myth that stress is always bad for learning. The term "stress" has been narrowed by habitual use to equate with the negative outcome of distress; this article takes an alternative view that ultimately rejects the myth that demonises stress. The avoidance of distress is important, but a broader view of stress as something that can have either positive or negative outcomes is considered. PROPOSAL: We propose that stress is important for learning and stress-related growth. We explore the little-mentioned concept of eustress (good stress) as a counter to the more familiar concept of distress. We further consider that the negative associations of stress may contribute to its negative impact. The impact of stress on learning should be deliberately and carefully considered. We offer a hypothetical learning journey that considers the cause of potential stress, a stressor, and how a stressor is moderated to result in stress that may influence learning either by positively challenging the learner or by functioning as a hindrance to learning. CONCLUSIONS: In thinking more positively about stress, health professional educators may better support the student's learning journey.

Identifying medical students at risk of underperformance from significant stressors.

BACKGROUND: Stress is associated with poorer academic performance but identifying vulnerable students is less clear. A series of earthquakes and disrupted learning environments created an opportunity to explore the relationships among stress, student factors, support and academic performance within a medical course. METHODS: The outcomes were deviations from expected performances on end of year written and clinical examinations. The predictors were questionnaire-based measures of connectedness/support, impact of the earthquakes, safety, depression, anxiety, stress, resilience and personality. RESULTS: The response rate was 77%. Poorer than expected performance on all examinations was associated with greater disruptions to living arrangements and fewer years in the country; on the written examination with not having a place to study; and on the clinical examination with relationship status, not having the support of others, less extroversion, and feeling less safe. There was a suggestion of a beneficial association with some markers of stress. CONCLUSION: We show that academic performance is assisted by students having a secure physical and emotional base. The students who are most vulnerable are those with fewer social networks, and those who are recent immigrants.

Medical faculty opinions of peer tutoring.

CONTEXT AND OBJECTIVES: Peer tutoring is a well-researched and established method of learning defined as 'a medical student facilitating the learning of another medical student'. While it has been adopted in many medical schools, other schools may be reluctant to embrace this approach. The attitude of the teaching staff, responsible for organizing and or teaching students in an undergraduate medical course to formal peer teaching will affect how it is introduced and operationalized. This study elicits faculty opinions on how best to introduce peer tutoring for medical students. METHODS: Structured telephone interviews were recorded, transcribed and analyzed using thematic analysis. The interviews were with medically qualified staff responsible for organizing or teaching undergraduate medical students at a New Zealand medical school. Six questions were posed regarding perceived advantages and disadvantages of peer tutoring and how the school and staff could support a peer-tutoring scheme if one was introduced. FINDINGS: Staff generally supported the peer tutoring concept, offering a safe environment for learning with its teachers being so close in career stage to the learners. They also say disadvantages when the student-teachers imparted wrong information and when schools used peer tutoring to justify a reduction in teaching staff. Subjects felt that faculty would be more accepting of peer tutoring if efforts were made to build staff 'buy in' and empowerment, train peer tutors and introduce a solid evaluation process. CONCLUSIONS: Staff of our school expressed some concerns about peer tutoring that are not supported in the literature, signaling a need for better communication about the benefits and disadvantages of peer tutoring.

Comparison of UMAT scores and GPA in prediction of performance in medical school: a national study.

CONTEXT: Medical schools continue to seek robust ways to select students with the greatest aptitude for medical education, training and practice. Tests of general cognition are used in combination with markers of prior academic achievement and other tools, although their predictive validity is unknown. This study compared the predictive validity of the Undergraduate Medicine and Health Sciences Admission Test (UMAT), the admission grade point average (GPA), and a combination of both, on outcomes in all years of two medical programmes. METHODS: Subjects were students (n = 1346) selected since 2003 using UMAT scores and attending either of New Zealand's two medical schools. Regression models incorporated demographic data, UMAT scores, admission GPA and performance on routine assessments. RESULTS: Despite the different weightings of UMAT used in selection at the two institutions and minor variations in student demographics and programmes, results across institutions were similar. The net predictive power of admission GPA was highest for outcomes in Years 2 and 5 of the 6-year programme, accounting for 17-35% of the variance; UMAT score accounted for < 10%. The highest predictive power of the UMAT score was 9.9% for a Year 5 written examination. Combining UMAT score with admission GPA improved predictive power slightly across all outcomes. Neither UMAT score nor admission GPA predicted outcomes in the final trainee intern year well, although grading bands for this year were broad and numbers smaller. CONCLUSIONS: The ability of the general cognitive test UMAT to predict outcomes in major assessments within medical programmes is relatively minor in comparison with that of the admission GPA, but the UMAT score adds a small amount of predictive power when it is used in combination with the GPA. However, UMAT scores may predict outcomes not studied here, which underscores the need for further validation studies in a range of settings.

How well do selection tools predict performance later in a medical programme?

The choice of tools with which to select medical students is complex and controversial. This study aimed to identify the extent to which scores on each of three admission tools (Admission GPA, UMAT and structured interview) predicted the outcomes of the first major clinical year (Y4) of a 6 year medical programme. Data from three student cohorts (n = 324) were analysed using regression analyses. The Admission GPA was the best predictor of academic achievement in years 2 and 3 with regression coefficients (B) of 1.31 and 0.9 respectively (each P < 0.001). Furthermore, Admission GPA predicted whether or not a student was likely to earn 'Distinction' rather than 'Pass' in year 4. In comparison, UMAT and interview showed low predictive ability for any outcomes. Interview scores correlated negatively with those on the other tools. None of the tools predicted failure to complete year 4 on time, but only 3% of students fell into this category. Prior academic achievement remains the best measure of subsequent student achievement within a medical programme. Interview scores have little predictive value. Future directions include longer term studies of what UMAT predicts, and of novel ways to combine selection tools to achieve the optimum student cohort.

Moving a formative test from a paper-based to a computer-based format. A student viewpoint.

BACKGROUND: A paper-based test was changed to a computer-based format. Students completed the test over a 2-week period on any computer with internet access. AIM: To determine the acceptability to students of the computer-based format, whether resources were used by students during the test, the value of receiving an immediate score, positive aspects of the computer format and areas for improvement. METHODS: Students completed an online survey containing closed questions (Likert scale) and free text questions. RESULTS: A large majority of respondents had easy access to a computer, found it easy to complete the test in the time given and did not use resources to answer the test questions. The most cited benefits were flexibility and convenience in being able to choose both the location and time for taking the test. A smaller majority found it useful to get immediate feedback. The possibility of students 'cheating' because of the ability to use resources during the test was seen as problematic. Some students felt that the test appeared to lack importance because of the flexibility permitted. CONCLUSIONS: From a student perspective, the computer was an acceptable platform for delivering a formative assessment comprising multiple choice questions (MCQs).

The clinical skills experience of rural immersion medical students and traditional hospital placement students: a student perspective.

BACKGROUND: Recent decades have seen an international trend for the development of undergraduate medical programmes in rural locations. These have been considered educationally equivalent alternatives to traditional hospital-based programmes. A pilot Rural Medical Immersion Programme (RMIP) was launched at the University of Otago. AIMS: To examine the clinical skills experience of RMIP students and to compare it to that of fifth-year students based in the traditional, often urban and hospital-based, rotations. METHODS: An online questionnaire was completed by 23 medical students: six RMIP students and 17 hospital-based students. Students rated their level of experience in a variety of skills and their self-perceived competence for performing these skills after their fifth year. Total experience and confidence was compared using Mann-Whitney U test, as were subsets of skills. RESULTS: There was no difference found in the total clinical skills experience and confidence between RMIP and traditional students. RMIP students reported greater experience of patient examination and patient education skills; traditional students reported greater experience and confidence in investigation and interpretative skills. CONCLUSION: Clinical skills experience of the RMIP students is at least equivalent to that of their peers in the tertiary hospital setting. However, attention may be needed in the development of 'investigative and interpretative skills' for rural immersion students.

Joining the dots: conditional pass and programmatic assessment enhances recognition of problems with professionalism and factors hampering student progress.

BACKGROUND: Programmatic assessment that looks across a whole year may contribute to better decisions compared with those made from isolated assessments alone. The aim of this study is to describe and evaluate a programmatic system to handle student assessment results that is aligned not only with learning and remediation, but also with defensibility. The key components are standards based assessments, use of "Conditional Pass", and regular progress meetings. METHODS: The new assessment system is described. The evaluation is based on years 4-6 of a 6-year medical course. The types of concerns staff had about students were clustered into themes alongside any interventions and outcomes for the students concerned. The likelihoods of passing the year according to type of problem were compared before and after phasing in of the new assessment system. RESULTS: The new system was phased in over four years. In the fourth year of implementation 701 students had 3539 assessment results, of which 4.1% were Conditional Pass. More in-depth analysis for 1516 results available from 447 students revealed the odds ratio (95% confidence intervals) for failure was highest for students with problems identified in more than one part of the course (18.8 (7.7-46.2) p < 0.0001) or with problems with professionalism (17.2 (9.1-33.3) p < 0.0001). The odds ratio for failure was lowest for problems with assignments (0.7 (0.1-5.2) NS). Compared with the previous system, more students failed the year under the new system on the basis of performance during the year (20 or 4.5% compared with four or 1.1% under the previous system (p < 0.01)). CONCLUSIONS: The new system detects more students in difficulty and has resulted in less "failure to fail". The requirement to state conditions required to pass has contributed to a paper trail that should improve defensibility. Most importantly it has helped detect and act on some of the more difficult areas to assess such as professionalism.

Health professional education and practice in preventing and controlling infections in New Zealand: a review to inform strategies for enhancing practitioner competencies and patient safety.

Objective: Quality assurance for reducing infections is a key objective of the WHO's global action plan targeting antimicrobial resistance, yet no studies have employed a multifaceted approach to review health professional education and practice in infection prevention and control (IPC). This study completed such a review. Methods and analysis: New Zealand medical and nursing curricula were analysed for IPC-related teaching and assessment. Clinicians (undergraduate to senior) received peer-expert evaluation while performing procedures demonstrating IPC competencies. Patient and clinician self-evaluation followed. Hospital IPC practice monitoring was also reviewed. Results: Medical curricula had approximately twice the total IPC-related theory compared with nursing (79.71 vs 41.66 hours), emphasising microbiology. IPC theory in nursing curricula was applied, emphasising health and safety. Junior nursing students were rigorously taught (16.17 hours) and assessed (2.91 hours) in practical IPC competencies, whereas little practical instruction (2.62 hours) and no formal assessment existed for junior medical students. IPC teaching chiefly occurred during medical students' senior clinical years, and was opportunistic, rotation-specific or in introductory sessions. Senior medical and nursing students were expected to be IPC-proficient but no formal assessment occurred. Peer review generally revealed satisfactory practice, however both professions had lapses with hand hygiene, asepsis and incorrect donning, removal and use of personal protective equipment. Clinician confidence in providing and being peer-reviewed for best IPC practice, and patients' confidence in receiving best IPC care, was positively associated with clinician experience. Trainee interns, whose confidence in IPC practice was not matched by the same desire for monitoring/feedback as senior colleagues, were the exception. Conclusion: Multifaceted approaches to IPC quality assurance have utility in identifying gaps, reducing infection transmission and reassuring staff and patients.

The employment gap: the relationship between medical student career choices and the future needs of the New Zealand medical workforce.

AIMS: To determine the career decision intentions of graduating doctors, and the relationship between these intentions and the predicted medical workforce needs in New Zealand in 10 years' time. METHODS: A workforce forecasting model developed by the Ministry of Health (MOH) has been used to predict the proportion of doctors required in each medical specialty in 2028 in New Zealand. The future work intentions of recently graduated doctors at the Universities of Auckland and Otago were collected from the Medical Student Outcomes Data (MSOD), and compared with these predicted needs. RESULTS: Between 2013 and 2017, 2,292 doctors graduated in New Zealand, of whom 1,583 completed the MSOD preferences section (response rate 69%). Of these only 50.1% had decided on a future medical specialty. The most popular were surgical specialties (26.2%), general practice (20.7%), and internal medicine (11.0%). Compared to the MOH workforce forecast model there appears to be insufficient interest in general practice at the time of graduation. CONCLUSIONS: To shape the medical workforce to meet forecast needs, multiple stakeholders will need to collaborate, with a special focus on the early postgraduate years, as many doctors have yet to decide on specialisation.

Developing New Zealand's medical workforce: realising the potential of longitudinal career tracking.

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.

"You can do it late at night or in the morning. You can do it at home, I did it with my flatmate." The educational impact of an OSCE.

BACKGROUND: The use of an objective structured clinical examination (OSCE) has been a powerful influence on doctor training but assessments do not always drive study behaviour in predictable ways. AIMS: To investigate the impact an OSCE has on study behaviours by exploring how 5th year medical students identify what to learn for a summative OSCE and the role of the clinical environment in their preparation. METHODS: A semi-structured questionnaire survey asked about strategies used by students to prepare for the OSCE. Focus group interviews explored successful methods of preparation for the OSCE. Themes were identified and classified. RESULTS: The questionnaire response rate was 84%. Topic identification was usually from the list of examinable problems, past OSCE papers and a booklet prepared by a previous student containing a series of OSCE checklists. The study behaviours of students preparing for the OSCE exam were predominantly to practise on each other, and to rehearse routines. Strategic and efficient study habits were favoured over conscious utilization of the clinical environment. CONCLUSION: The expectation that an OSCE drives learning into the clinical workplace was not supported by this study. This suggests the role of clinical experience in helping students prepare for the exam may be more subliminal, or that an OSCE is more as a test of psychomotor skills than a marker of clinical experience. An unexpected benefit may be to drive more collaborative learning.