Asthma symptoms, spirometry and air pollution exposure in schoolchildren in an informal settlement and an affluent area of Nairobi, Kenya.

BACKGROUND: Although 1 billion people live in informal (slum) settlements, the consequences for respiratory health of living in these settlements remain largely unknown. This study investigated whether children living in an informal settlement in Nairobi, Kenya are at increased risk of asthma symptoms. METHODS: Children attending schools in Mukuru (an informal settlement in Nairobi) and a more affluent area (Buruburu) were compared. Questionnaires quantified respiratory symptoms and environmental exposures; spirometry was performed; personal exposure to particulate matter (PM2.5) was estimated. RESULTS: 2373 children participated, 1277 in Mukuru (median age, IQR 11, 9-13 years, 53% girls), and 1096 in Buruburu (10, 8-12 years, 52% girls). Mukuru schoolchildren were from less affluent homes, had greater exposure to pollution sources and PM2.5. When compared with Buruburu schoolchildren, Mukuru schoolchildren had a greater prevalence of symptoms, 'current wheeze' (9.5% vs 6.4%, p=0.007) and 'trouble breathing' (16.3% vs 12.6%, p=0.01), and these symptoms were more severe and problematic. Diagnosed asthma was more common in Buruburu (2.8% vs 1.2%, p=0.004). Spirometry did not differ between Mukuru and Buruburu. Regardless of community, significant adverse associations were observed with self-reported exposure to 'vapours, dusts, gases, fumes', mosquito coil burning, adult smoker(s) in the home, refuse burning near homes and residential proximity to roads. CONCLUSION: Children living in informal settlements are more likely to develop wheezing symptoms consistent with asthma that are more severe but less likely to be diagnosed as asthma. Self-reported but not objectively measured air pollution exposure was associated with increased risk of asthma symptoms.

Parenting Science Gang: radical co-creation of research projects led by parents of young children.

BACKGROUND: Parents are increasingly searching online for information supported by research but can find it difficult to identify results relevant to their own experiences. More troublingly, a number of studies indicate that parenting information found online often can be misleading or wrong. The goal of the Parenting Science Gang (PSG) project was to use the power of the Internet to help parents ask questions they wanted to have answered by scientific research and to feel confident in assessing research evidence. METHODS: By using Facebook to recruit groups and facilitate interactions, PSG was able to engage fully the target public of parents of young children in the radical co-production of scientific studies, while not creating an undue burden on time or restricting participants due to disability, financial status or location. By giving parents true partnership and control of creation of projects, PSG ensured that the chosen questions were ones that were of most relevance and interest to them. RESULTS: This paper presents a summary of eight projects, with three in more detail, designed and implemented by PSG Facebook groups in collaboration with experts. Most projects had health related themes, often prompted by dissatisfaction with treatment of parents by health professionals or by feelings of being marginalised by pregnancy and motherhood, as well as by the lack of evidence for their questions and concerns. The PSG approach meant that these frustrations were channelled into actions. All eight of the PSG groups engaged in meaningful interactions with experts and co-produced studies with the groups defining the questions of interest. CONCLUSIONS: This radically user-led design meant that the PSG staff and the collaborating experts had to live with a high degree of uncertainty. Nevertheless, PSG achieved its goal of academically productive, truly co-produced projects, but as important were the positive effects it had on many of the participants, both parents and experts. At the point of writing this paper, PSG projects have led to outputs including at least eight papers published, in press or in preparation, seven conference presentations, testimony to the Infant Feeding All-Party Parliamentary Group, and with more to come.

Interprofessional training for final year healthcare students: a mixed methods evaluation of the impact on ward staff and students of a two-week placement and of factors affecting sustainability.

BACKGROUND: Multiple care failings in hospitals have led to calls for increased interprofessional training in medical education to improve multi-disciplinary teamwork. Providing practical interprofessional training has many challenges and remains uncommon in medical schools in the UK. Unlike most previous research, this evaluation of an interprofessional training placement takes a multi-faceted approach focusing not only on the impact on students, but also on clinical staff delivering the training and on outcomes for patients. METHODS: We used mixed methods to examine the impact of a two-week interprofessional training placement undertaken on a medical rehabilitation ward by three cohorts of final year medical, nursing and therapy students. We determined the effects on staff, ward functioning and participating students. Impact on staff was evaluated using the Questionnaire for Psychological and Social factors at work (QPSNordic) and focus groups. Ward functioning was inferred from standard measures of care including length of stay, complaints, and adverse events. Impact on students was evaluated using the Readiness for Interprofessional Learning Survey (RIPLS) among all students plus a placement survey among medical students. RESULTS: Between 2007 and 2010, 362 medical students and 26 nursing and therapy students completed placements working alongside the ward staff to deliver patient care. Staff identified benefits including skills recognition and expertise sharing. Ward functioning was stable. Students showed significant improvements in the RIPLS measures of Teamwork, Professional Identity and Patient-Centred Care. Despite small numbers of students from other professions, medical students' rated the placement highly. Increasing student numbers and budgetary constraints led to the cessation of the placement after three years. CONCLUSIONS: Interprofessional training placements can be delivered in a clinical setting without detriment to care and with benefits for all participants. While financial support is a necessity, it appears that having students from multiple professions is not critical for a valuable training experience; staff from different professions and students from a single profession can work successfully together. Difficulty in aligning the schedules of different student professions is commonly cited as a barrier to interprofessional training. Our experience challenges this and should encourage provision of authentic interprofessional training experience.

Predictors of professional behaviour and academic outcomes in a UK medical school: A longitudinal cohort study.

BACKGROUND: Over the past 70 years, there has been a recurring debate in the literature and in the popular press about how best to select medical students. This implies that we are still not getting it right: either some students are unsuited to medicine or the graduating doctors are considered unsatisfactory, or both. AIM: To determine whether particular variables at the point of selection might distinguish those more likely to become satisfactory professional doctors, by following a complete intake cohort of students throughout medical school and analysing all the data used for the students' selection, their performance on a range of other potential selection tests, academic and clinical assessments throughout their studies, and records of professional behaviour covering the entire five years of the course. METHODS: A longitudinal database captured the following anonymised information for every student (n = 146) admitted in 2007 to the Hull York Medical School (HYMS) in the UK: demographic data (age, sex, citizenship); performance in each component of the selection procedure; performance in some other possible selection instruments (cognitive and non-cognitive psychometric tests); professional behaviour in tutorials and in other clinical settings; academic performance, clinical and communication skills at summative assessments throughout; professional behaviour lapses monitored routinely as part of the fitness-to-practise procedures. Correlations were sought between predictor variables and criterion variables chosen to demonstrate the full range of course outcomes from failure to complete the course to graduation with honours, and to reveal clinical and professional strengths and weaknesses. RESULTS: Student demography was found to be an important predictor of outcomes, with females, younger students and British citizens performing better overall. The selection variable "HYMS academic score", based on prior academic performance, was a significant predictor of components of Year 4 written and Year 5 clinical examinations. Some cognitive subtest scores from the UK Clinical Aptitude Test (UKCAT) and the UKCAT total score were also significant predictors of the same components, and a unique predictor of the Year 5 written examination. A number of the non-cognitive tests were significant independent predictors of Years 4 and 5 clinical performance, and of lapses in professional behaviour. First- and second-year tutor ratings were significant predictors of all outcomes, both desirable and undesirable. Performance in Years 1 and 2 written exams did not predict performance in Year 4 but did generally predict Year 5 written and clinical performance. CONCLUSIONS: Measures of a range of relevant selection attributes and personal qualities can predict intermediate and end of course achievements in academic, clinical and professional behaviour domains. In this study HYMS academic score, some UKCAT subtest scores and the total UKCAT score, and some non-cognitive tests completed at the outset of studies, together predicted outcomes most comprehensively. Tutor evaluation of students early in the course also identified the more and less successful students in the three domains of academic, clinical and professional performance. These results may be helpful in informing the future development of selection tools.

Examiner and simulated patient ratings of empathy in medical student final year clinical examination: are they useful?

BACKGROUND: Many medical schools state that empathy is important and have curricular learning outcomes covering its teaching. It is thought to be useful in team-working, good bedside manner, patient perspective taking, and improved patient care. Given this, one might expect it to be measured in assessment processes. Despite this, there is relatively little literature exploring how measures of empathy in final clinical examinations in medical school map onto other examination scores. Little is known about simulated patient (actors) rating of empathy in examinations in terms of inter-rater reliability compared with clinical assessors or correlation with overall examination results. METHODS: Examiners in final year clinical assessments in one UK medical school rated 133 students on five constructs in Objective Structured Long Examination Record (OSLER) with real patients: gathering information, physical examination, problem solving, managing the diagnosis, and relationship with the patient. Scores were based on a standardized well-established penalty point system. In separate Objective Structured Clinical Examination (OSCE) stations, different examiners used the same penalty point system to score performance in both interactional and procedural stations. In the four interaction-based OSCE stations, examiners and simulated patient actors also independently rated empathy of the students. RESULTS: The OSLER score, based on penalty points, had a correlation of -0.38 with independent ratings of empathy from the interactional OSCE stations. The intra-class correlation (a measure of inter-rater reliability) between the observing clinical tutor and ratings from simulated patients was 0.645 with very similar means. There was a significant difference between the empathy scores of the 94 students passing the first part of the sequential examination, based on combined OSCE and OSLER scores (which did not include the empathy scores), and 39 students with sufficient penalty points to trigger attendance for the second part (Cohen's d = 0.81). CONCLUSIONS: These findings suggest that empathy ratings are related to clinical performance as measured by independent examiners. Simulated patient actors are able to give clinically meaningful assessment scores. This gives preliminary evidence that such empathy ratings could be useful for formative learning, and bolsters the call for more research to test whether they are robust enough to be used summatively.

Identifying attributes required by Foundation Year 1 doctors in multidisciplinary teams: a tool for performance evaluation.

BACKGROUND: Effective working in multidisciplinary teams (MDTs) is promoted as essential in ensuring good healthcare outcomes, suggesting that an understanding exists of the relationship between outcomes and the attributes needed by individuals to function effectively in the MDT. While the characteristics of effective teamwork have been described, the attributes needed by individual MDT members have not been investigated. To address this, the study focuses on newly qualified Foundation Year 1 (FY1) doctors, creating and testing a tool to evaluate their performance in the MDT. METHODS: Repertory grid technique was used to elicit attributes needed by FY1 doctors to function effectively in the MDT. Study participants (all experienced MDT members) used these to evaluate MDT working by FY1 doctor colleagues. Data on 57 FY1 doctors were collected from 95 MDT members working in five hospitals. Participants also ranked the attributes in terms of importance for effective team functioning and rated an 'Ideal' FY1 doctor. RESULTS: The repertory grid permitted differentiation between groups of FY1 doctors' MDT performance. FY1 doctors who undertook interprofessional training were rated no differently than UK-trained graduates without such training. UK-trained graduates were rated significantly higher on all attributes than non-UK-trained graduates. Overall, FY1 doctors were rated lower than the 'Ideal'. Factor analysis and rankings suggested tensions between clinical attributes needed for good team functioning and more 'social' attributes. CONCLUSIONS: This study demonstrates the potential of repertory grid methodology in eliciting attributes that are important for effective teamworking, and using these to evaluate MDT working by FY1 doctors.

Can personal qualities of medical students predict in-course examination success and professional behaviour? An exploratory prospective cohort study.

BACKGROUND: Over two-thirds of UK medical schools are augmenting their selection procedures for medical students by using the United Kingdom Clinical Aptitude Test (UKCAT), which employs tests of cognitive and non-cognitive personal qualities, but clear evidence of the tests' predictive validity is lacking. This study explores whether academic performance and professional behaviours that are important in a health professional context can be predicted by these measures, when taken before or very early in the medical course. METHODS: This prospective cohort study follows the progress of the entire student cohort who entered Hull York Medical School in September 2007, having taken the UKCAT cognitive tests in 2006 and the non-cognitive tests a year later. This paper reports on the students' first and second academic years of study. The main outcome measures were regular, repeated tutor assessment of individual students' interpersonal skills and professional behaviour, and annual examination performance in the three domains of recall and application of knowledge, evaluation of data, and communication and practical clinical skills. The relationships between non-cognitive test scores, cognitive test scores, tutor assessments and examination results were explored using the Pearson product-moment correlations for each group of data; the data for students obtaining the top and bottom 20% of the summative examination results were compared using Analysis of Variance. RESULTS: Personal qualities measured by non-cognitive tests showed a number of statistically significant relationships with ratings of behaviour made by tutors, with performance in each year's objective structured clinical examinations (OSCEs), and with themed written summative examination marks in each year. Cognitive ability scores were also significantly related to each year's examination results, but seldom to professional behaviours. The top 20% of examination achievers could be differentiated from the bottom 20% on both non-cognitive and cognitive measures. CONCLUSIONS: This study shows numerous significant relationships between both cognitive and non-cognitive test scores, academic examination scores and indicators of professional behaviours in medical students. This suggests that measurement of non-cognitive personal qualities in applicants to medical school could make a useful contribution to selection and admission decisions. Further research is required in larger representative groups, and with more refined predictor measures and behavioural assessment methods, to establish beyond doubt the incremental validity of such measures over conventional cognitive assessments.

A final clinical examination using a sequential design to improve cost-effectiveness.

CONTEXT: Good examinations have a number of characteristics, including validity, reliable scores, educational impact, practicability and acceptability. Scores from the objective structured clinical examination (OSCE) are more reliable than the single long case examination, but concerns about its validity have led to modifications and the development of other models, such as the mini-clinical evaluation exercise (mini-CEX) and the objective structured long examination record (OSLER). These retain some of the characteristics of the long case, but feature repeated encounters and more structure. Nevertheless, the practical considerations and costs associated with mounting large-scale examinations remain significant. The lack of metrics handicaps progress. This paper reports a system whereby a sequential design concentrates limited resources where they are most needed in order to maintain the reliability of scores and practicability at the pass/fail interface. METHODS: We analysed data pertaining to the final examination administered in 2009. In the complete final examination, candidates see eight real patients (the OSLER) and encounter 12 OSCE stations. Candidates whose performance is judged as entirely satisfactory after the first four patients and six OSCE stations are not examined further. The others - about a third of candidates - see the remaining patients and stations and are judged on the complete examination. Reliability was calculated from the scores of all candidates on the first part of the examination using generalisability theory and practicability in terms of financial resources. The functioning of the sequential system was assessed by the ability of the first part of the examination to predict the final result for the cohort. RESULTS: Generalisability for the OSLER was 0.63 after four patients and 0.77 after eight patients. The OSCE was less reliable (0.38 after six stations and 0.55 after 12). There was only a weak correlation between the OSLER and the OSCE. The first stage was highly predictive of the results of the second stage. Savings facilitated by the sequential design amounted to approximately GBP 30,000. CONCLUSIONS: The overall utility of examinations involves compromise. The system described provides good perceived validity with reasonably reliable scores; a sequential design can concentrate resources where they are most needed and still allow wide sampling of tasks.

Lessons from medical students' perceptions of learning reflective skills: a multi-institutional study.

BACKGROUND: A core competency during undergraduate medical training is the development of reflective learning. The current literature is limited to demonstrating how reflective learning has been implemented or the approaches to its development. There is a lack of insight into students' perceptions of reflection and the factors that support development of reflective practice. Bridging this gap may provide insight into how reflective learning within the curriculum can be better developed to increase engagement from learners. METHODS: Eight focus group interviews with second year students from four UK medical schools were held. Results were thematically analysed. KEY FINDINGS: Students have a high level of understanding of the purpose of reflection in practice but they perceive that there is a tension between public and private reflections. Assessment of the reflective process was perceived to be useful for developing reflective skills but grading of their reflective writing was not considered to be useful. Staff who champion the development of reflective skills and mentor students were perceived to play key roles in aiding the development of reflective skills. Appropriate experiences were seen to be a key part of developing reflective skills. CONCLUSION: These findings highlight potential ways to revise and improve engagement with the reflective learning components of undergraduate courses.

Examination results of medical students with dyslexia.

CONTEXT: dyslexia is a learning disorder, the primary sign of which is significant difficulty in learning to read and spell. However, accumulating evidence suggests that many people with dyslexia can overcome their reading difficulties and enjoy high levels of educational success. There is debate about the appropriateness of different forms of summative assessment for people with dyslexia, but there is little research investigating different examination formats, particularly in higher education, including medical education. Currently, medical school examinations comprise a range of different assessments, both written and performance-based, offering an opportunity to compare performance on different formats. This study compared results between students with and without dyslexia on all summative assessment types used at one UK medical school. METHODS: examination scores were collated for all summative Year 1 and 2 examinations at Hull York Medical School (HYMS) over four cohorts entering from 2004 to 2007. These included scores on two types of forced-choice question (multiple-choice and extended matching question) examinations, on short written answer examinations and on performance in a 16-station objective structured clinical examination (OSCE). Results for written answers were gathered separately for basic science questions and for questions involving critical analysis and evidence-based medicine. RESULTS: an overall multivariate analysis of covariance (mancova) on examinations across both years controlling for gender, ethnicity and age on entry indicated that there was no significant overall effect of dyslexia on examination results. Regression analysis further showed that dyslexia was not a significant predictor on any of the examination forms in Year 1 or Year 2. CONCLUSIONS: there is no indication that any of the assessment methods used in HYMS, in common with many other medical schools, disadvantage students with dyslexia in comparison with their peers. In the light of these findings, we support the current view that a variety of assessment types should be included in the assessment of all medical students, as is already considered to be best practice.

Experiences of problem-based learning in the UK.

BACKGROUND: Problem-based learning (PBL) in the UK began with the first version of Tomorrow's Doctors, published in 1993. About 12 of the 32 UK medical schools deliver PBL programmes. At a recent workshop, representatives from 10 UK medical schools, one dental school and one veterinary school discussed implementations, strengths and weaknesses of their PBL curricula. CONTEXT: The goal of the workshop was to summarise our 'warts and all' experiences of PBL. A concern expressed by the group is that when a PBL programme runs into difficulties, it is easy to blame PBL rather than what may be issues in implementation or culture. There was strong agreement that PBL performed well, works well. Conversely, PBL performed badly should not be performed at all! INNOVATION: The schools representatives outlined the strengths and weaknesses based on collective experience, and offered lessons and tips on how to help PBL succeed. By combining and sharing information and resources from various approaches, a picture emerged of the factors that help create a positive and effective PBL experience, and, conversely, the factors that will make it unlikely to work. IMPLICATIONS: Points emerging from the workshop were that strong support from senior leadership is critical, people who will not 'sign up' must not be allowed to undermine the effort, tutors should want the role rather than being co-opted, tutors should be integrated into faculty and curriculum design, induction for staff and students with ongoing tutor development is essential and, finally, personal experience shows that PBL, performed well, works well!

Undergraduate medical student attitudes to the peer assessment of professional behaviours in two medical schools.

The objective of this study was to investigate medical school student views on the peer assessment of professional behaviours. Focus groups were held with students at two northern England medical schools which were using peer assessment. The study showed that preparing students to give and receive feedback was a key aspect in the successful delivery of peer assessment. Medical school students are generally positive about the peer assessment of professional behaviours. However, they expressed mixed views about anonymity and how information was to be used. The results imply that peer assessment could offer valuable feedback for formative learning.