Performance of academically at-risk medical students in a problem-based learning programme: a preliminary report.

INTRODUCTION: Racially segregated schooling, a legacy of Apartheid policies, continues to hamper education in South Africa. Students entering university from suboptimal circumstances are at significant risk of demonstrating poor academic performance and dropping out of their programmes. Attempts to address the educational needs of these students have included the introduction of extended medical programmes at several universities. Such a programme, the Academic Development Programme (ADP), was implemented at the University of Cape Town in 1991. Over the past decade the programme has graduated more than 100 students. Upon implementation of a new problem-based learning (PBL) programme in 2002, the ADP was discontinued and all students were entered directly into the new PBL programme. Students who demonstrate a need for additional academic support by the end of the first semester enter the Intervention Programme for 1 year before proceeding to the second semester of the PBL programme. An interim analysis was performed to compare the retention rates and academic performance of academically at-risk students in the new PBL programme and the ADP. METHODS: The records of all academically at-risk students entering the ADP (1991-2000) and the new PBL programme (2002) were reviewed. Retention rates for all years of study, and academic performance in the fourth year clerkship courses of the respective programmes were compared. RESULTS: A total of 239 academically at-risk students in the ADP and 43 at-risk students in the new PBL programme were studied. The median retention rates, per year of study, for at-risk students in the PBL programme was significantly better than for at-risk students in the ADP (p<0.02). Academic performance of the at-risk students in all the fourth year clinical clerkship courses of the PBL programme was significantly better than the mean performance over 10 years for at-risk students in the same fourth year courses in the ADP. CONCLUSION: The introduction of PBL at the University of Cape Town has not had a deleterious effect on the performance of academically at-risk medical students. Interim analysis suggests that retention rates and academic performance in the PBL programme are better than those achieved in the extended traditional programme.

Formative assessment promotes learning in undergraduate clinical clerkships.

INTRODUCTION: Clinical clerkships, typically situated in environments lacking educational structure, form the backbone of undergraduate medical training. The imperative to develop strategies that enhance learning in this context is apparent. This study explored the impact of longitudinal bedside formative assessment on student learning in a medical clerkship. METHODS: We studied a class of 4th-year students completing a 14-week medical clerkship at the University of Cape Town in South Africa. Clinician educators assessed student performance during weekly bedside teaching sessions using blinded patient encounters (in which students had no prior knowledge of the patient's diagnosis or access to the clinical records). Student feedback was standardised using performance rating scales. The impact of formative assessment on student learning was determined from questionnaire responses. RESULTS: A total of 575 formative assessments took place during the study period. Students perceived blinded patient encounters to be a valuable learning activity that improved their clinical reasoning skills and assessed progress fairly. They reported that feedback helped inform them of their level of competence and learning needs, motivated them to read more, and significantly improved their participation in patient-centred learning activities. Participating clinicians agreed that this formative assessment strategy enhanced the learning potential of bedside teaching sessions. CONCLUSIONS: Longitudinal formative assessment, using blinded patient encounters, was successfully integrated into undergraduate clerkship bedside teaching. According to both students and staff this assessment strategy enhanced bedside learning and improved student participation in patient-centred learning activities during the clerkship.

Formative Assessment Promotes Learning in Undergraduate Clinical Clerkship

INTRODUCTION: Clinical clerkships; typically situated in environments lacking educational structure; form the backbone of undergraduate medical training. The imperative to develop strategies that enhance learning in this context is apparent. This study explored the impact of longitudinal bedside formative assessment on student learning in a medical clerkship.METHODS: We studied a class of 4th-year students completing a 14-week medical clerkship at the University of Cape Town in South Africa. Clinician educators assessed student performance during weekly bedside teaching sessions using blinded patient encounters (in which students had no prior knowledge of the patient's diagnosis or access to the clinical records). Student feedback was standardised using performance rating scales. The impact of formative assessment on student learning was determined from questionnaire responses. RESULTS: A total of 575 formative assessments took place during the study period. Students perceived blinded patient encounters to be a valuable learning activity that improved their clinical reasoning skills and assessed progress fairly. They reported that feedback helped inform them of their level of competence and learning needs; motivated them to read more; and significantly improved their participation in patient-centred learning activities. Participating clinicians agreed that this formative assessment strategy enhanced the learning potential of bedside teaching sessions. CONCLUSIONS: Longitudinal formative assessment; using blinded patient encounters; was successfully integrated into undergraduate clerkship bedside teaching. According to both students and staff this assessment strategy enhanced bedside learning and improved student participation in patient-centred learning activities during the clerkship

Microscopic polyarteritis--a treatable cause of rapidly progressive renal failure due to necrotising glomerulonephritis.

The clinical features of 25 patients with microscopic polyarteritis are reviewed. Major indications of disease were haematuria and proteinuria accompanied by significant renal dysfunction, which was rapidly progressive in the majority of patients. Unrewarding investigations aimed at defining a cause of haematuria that could be treated surgically only served to delay diagnosis, which could be promptly made by renal biopsy. Early institution of cyclophosphamide therapy led to ablation of the inflammatory process and stabilisation of renal function. In men, who were affected twice as often as women, there was a striking association with employment in the goldmining industry.

Acute renal failure--10-year experience of the Johannesburg Hospital renal unit.

The 10-year experience of Johannesburg Hospital's renal unit in treating acute renal failure (ARF) is described; 290 patients were treated by haemodialysis--169 drawn from the surgical disciplines, 109 from the medical disciplines and 12 from obstetrics and gynaecology, suffering 55%, 41% and 33% mortality rates, respectively. The mortality rates were found to correlate strongly with the cumulative number of acute insults to renal function accruing as a result of the particular surgical or medical illness ('precipitating event') and culminating in ARF. Age was also shown to have a powerful influence on outcome, the survival rate falling steadily with each decade of life. A plea is made to limit the potential insults to renal function actively, particularly in the elderly, in an attempt to further reduce the high mortality rate with which ARF continues to be stubbornly associated.

Outcome of renal transplants with impaired renal function at 6 months.

At 6 months after kidney transplantation 59 adults with impaired renal function were divided into three groups according to their serum creatinine level: group I 150-199 mumol/l; group II 200-299 mumol/l; and group III greater than or equal to 300 mumol/l. These patients were followed up for 5 years or to graft loss when it became apparent that the eventual outcome was related to the degree of renal impairment at 6 months. Age of donor and age of recipient did not have a bearing on the eventual outcome nor did the frequency of acute tubular necrosis or rejection episodes. Patients with severely impaired renal function with serum creatinine levels greater than or equal to 300 mumol/l have a poor outlook but there are no particular prognostic features on which to base a forecast for the individual patient.

Pregnancy after renal transplantation.

During the 13 year period 1971 to 1984 there were 38 pregnancies in 21 renal transplant patients at the Johannesburg Hospital. Twenty-two ended with live births and included two sets of twins; there were nine spontaneous abortions, six therapeutic abortions, and one stillbirth. Maternal complications were mild in the majority but five patients suffered deterioration in renal function, two undergoing transplant nephrectomy as a result of this. There were seven neonatal deaths, including both sets of twins; death was due to prematurity in six and congenital malformation (diaphragmatic hernia) in one. A further infant had congenital pyloric stenosis which was corrected surgically. Pregnancies were analysed according to whether or not their outcome was successful. Those with a successful outcome had less exposure to warfarin during pregnancy (p = 0.0025) and showed a tendency towards lower immunosuppressive doses of prednisone and azathioprine although these did not reach significance. Although these results indicate an unhappy prognosis for both the mother and fetus, two redeeming features are to be noted. Pregnancy outcome improved markedly in the latter years, possibly owing to non-exposure to warfarin, less immunosuppression, and improvement in neonatal care, and four of the five mothers who suffered deterioration in renal function were notoriously unco-operative in their medical care. Pregnancy can only be recommended in the transplanted patient who has stable renal function, is compliant in taking of medications, and whose graft is of such age that the immunosuppressive drug dose is minimal. Warfarin should be avoided.

Source of cadaver kidneys for transplantation at Johannesburg Hospital.

The Johannesburg Hospital Renal Transplantation Unit obtains cadaver kidneys from throughout the Transvaal; they are also exchanged with other transplantation centres in the RSA. Analysis of the cause of death of kidney donors shows that motor vehicle accidents, suicide and cerebrovascular disease make up the majority. An encouraging feature has been the significant contribution from non-teaching hospitals and private institutions in the Johannesburg area and the effort made by more remote hospitals to help to ensure an adequate supply.