Phenomenographic study of basic science understanding-senior medical students' conceptions of fatigue.

INTRODUCTION: Helping students learn to apply their newly learned basic science knowledge to clinical situations is a long-standing challenge for medical educators. This study aims to describe how medical students' knowledge of the basic sciences is construed toward the end of their medical curriculum, focusing on how senior medical students explain the physiology of a given scenario. Methods A group of final-year medical students from two universities was investigated. Interviews were performed and phenomenographic analysis was used to interpret students' understanding of the physiology underlying the onset of fatigue in an individual on an exercise bicycle. RESULTS: Three categories of description depict the qualitatively different ways the students conceptualized fatigue. A first category depicts well integrated physiological and bio-chemical knowledge characterized by equilibrium and causality. The second category contains conceptions of finite amount of substrate and juxtaposition of physiological concepts that are not fully integrated. The third category exhibits a fragmented understanding of disparate sections of knowledge without integration of basic science and clinical knowledge. DISCUSSION: Distinctive conceptions of fatigue based with varying completeness of students' understanding characterized the three identified categories. The students' conceptions of fatigue were based on varying understanding of how organ systems relate and of the thresholds that determine physiological processes. Medical instruction should focus on making governing steps in biological processes clear and providing opportunity for causal explanations of clinical scenarios containing bio-chemical as well as clinical knowledge. This augments earlier findings by adding descriptions in terms of the subject matter studied about how basic science is applied by students in clinical settings.

Integrating virtual patients into courses: follow-up seminars and perceived benefit.

CONTEXT: The use of virtual patients (VPs) suggests promising effects on student learning. However, currently empirical data on how best to use VPs in practice are scarce. More knowledge is needed regarding aspects of integrating VPs into a course, of which student acceptance is one key issue. Several authors call for looking beyond technology to see VPs in relation to the course context. The follow-up seminar is proposed as an important aspect of integration that warrants investigation. METHODS: A cross-sectional explanatory study was performed in a clinical clerkship introduction course at four teaching hospitals affiliated to the same medical faculty. The VP-related activities were planned collaboratively by teachers from all four settings. However, each setting employed a different strategy to follow up the activity in the course. Sixteen questionnaire items were grouped into three scales pertaining to: perceived benefit of VPs; wish for more guidance on using VPs, and wish for assessment and feedback on VPs. Scale scores were compared across the four settings, which were ranked according to the level of intensity of students' processing of cases during VP follow-up activities. RESULTS: The perceived benefit of VPs and their usage were higher in the two intense-use settings compared with the moderate- and low-intensity settings. The wish for more guidance was high in the low- and one of the high-intensity settings. Students in all settings displayed little interest in more assessment and feedback regarding VPs. CONCLUSIONS: High case processing intensity was related to positive perceptions of the benefit of VPs. However, the low interest in more assessment and feedback on the use of VPs indicates the need to clearly communicate the added value of the follow-up seminar. The findings suggest that a more intense follow-up pays off in terms of the benefit perceived by students. This study illustrates the need to consider VPs from the perspective of a holistic course design and not as isolated add-ons.

What does it mean to be a good teacher and clinical supervisor in medical education?

The aim of this study was to describe the different ways medical teachers understand what constitutes a good teacher and a good clinical supervisor and what similarities and differences they report between them. Data was gathered through interviews with 39 undergraduate teachers at a medical university. The transcripts were analysed using a phenomenographic approach. Three categories regarding what it means to be a good teacher and clinical supervisor respectively were identified. Similarities between the two hierarchies were seen with the most inclusive categories of understanding what it means to be a good teacher or supervisor focuses on students' learning or growth. In the third category a good teacher and supervisor is seen as someone who conveys knowledge or shows how things are done. However, the role of being a clinical supervisor was perceived as containing a clearer focus on professional development and role modelling than the teacher role did. This is shown in the middle category where a good clinical supervisor is understood as a role model and someone who shares what it is like to be a doctor. The middle category of understanding what it means to be a good teacher instead focussing on the teacher as someone who responds to students' content requests in a partially student-centred perspective. In comparing the ways individual respondents understood the two roles, this study also implies that teachers appear to compartmentalise their roles as teachers and clinical supervisors respectively.

Experiencing virtual patients in clinical learning: a phenomenological study.

Computerised virtual patients (VPs) are increasingly being used in medical education. With more use of this technology, there is a need to increase the knowledge of students' experiences with VPs. The aim of the study was to elicit the nature of virtual patients in a clinical setting, taking the students' experience as a point of departure. Thirty-one students used VPs as a mandatory part of an early clinical rotation in rheumatology. Using the qualitative approach of phenomenology, we interviewed these students and then analysed data regarding their experiences of VPs as a learning activity. The result shows that students perceived VP activities in relation to actual patients, the clinical context and other learning activities. The VPs represented typical clinical cases which encouraged clinical reasoning and allowed for decision making. The students experienced the activities as integrating biomedical knowledge and clinical experience, providing structure that prepared for the unstructured clinical environment and patient encounters under unstressful conditions. However, the VPs were experienced as lacking the emotional interactivity and complexity of actual patients. Theoretical frameworks of clinical reasoning and experiential learning are suggested as foundations for further educational integration of VPs in the clinical environment. VP activities during clinical rotations provide experiences of clinical reality and allow students to solve problems actively. These features are dependent on VP technology but are also contingent on the surrounding environment.

What does it mean to be a mentor in medical education?

BACKGROUND: Mentor programmes are becoming increasingly common in undergraduate education. However, the meaning attached to being a mentor varies significantly. AIM: The aim of this study is to explore how teachers in medical and dental education understand their role as mentors. METHOD: Twenty mentors in two different mentor programmes for undergraduate medical and dental students were interviewed. The transcripts were analysed using a phenomenographic approach. RESULTS: The findings comprise three qualitatively different ways of understanding what it means to be a mentor, which are described as: (1) a mentor is someone who can answer questions and give advice, (2) a mentor is someone who shares what it means to be a doctor/dentist, and (3) a mentor is someone who listens and stimulates reflection. The way the mentors understood their role also affected what they did as mentors, their relationships with their mentees and their perceived benefits as mentors. CONCLUSIONS: Being a mentor can be perceived in qualitatively different ways also within the same mentor programme. This understanding affects the mentors' actions, their relationships with their mentees and their perceived benefits of being a mentor. Awareness of one's own understanding is important in improving practices and the findings of this study can be used by mentors, teachers and educational developers to facilitate improved effectiveness in mentor programmes, both for mentors and mentees.

The anatomy of learning anatomy.

The experience of clinical teachers as well as research results about senior medical students' understanding of basic science concepts has much been debated. To gain a better understanding about how this knowledge-transformation is managed by medical students, this work aims at investigating their ways of setting about learning anatomy. Second-year medical students were interviewed with a focus on their approach to learning and their way of organizing their studies in anatomy. Phenomenographic analysis of the interviews was performed in 2007 to explore the complex field of learning anatomy. Subjects were found to hold conceptions of a dual notion of the field of anatomy and the interplay between details and wholes permeated their ways of studying with an obvious endeavor of understanding anatomy in terms of connectedness and meaning. The students' ways of approaching the learning task was characterized by three categories of description; the subjects experienced their anatomy studies as memorizing, contextualizing or experiencing. The study reveals aspects of learning anatomy indicating a deficit in meaningfulness. Variation in approach to learning and contextualization of anatomy are suggested as key-elements in how the students arrive at understanding. This should be acknowledged through careful variation of the integration of anatomy in future design of medical curricula.

Being a mentor for undergraduate medical students enhances personal and professional development.

BACKGROUND: There is increasing evidence of the positive effects of mentoring in medical undergraduate programmes, but as far as we know, no studies on the effects for the mentors have yet been described in the field of medicine. AIM: This study aims to evaluate an undergraduate mentor programme from the mentors' perspective, focusing particularly on the effect of mentorship, the relationships between mentoring and teaching and the mentors' perceived professional and personal development. METHODS: Data was gathered through a questionnaire to all 83 mentors (response rate 75%) and semi-structured interviews with a representative sample of 10 mentors. RESULTS: Findings show, for example, that a majority of respondents developed their teaching as a result of their mentorship and improved their relations with students. Most respondents also claimed that being a mentor led to an increased interest in teaching and increased reflections regarding their own values and work practices. CONCLUSION: Being a mentor was perceived as rewarding and may lead to both personal and professional development.

Does an outcome-based approach to continuing medical education improve physicians' competences in rational prescribing?

BACKGROUND: Continuing medical education (CME) is compulsory in Iran, and traditionally it is lecture-based, which is mostly not successful. Outcome-based education has been proposed for CME programs. AIM: To evaluate the effectiveness of an outcome-based educational intervention with a new approach based on outcomes and aligned teaching methods, on knowledge and skills of general physicians (GPs) working in primary care compared with a concurrent CME program in the field of "Rational prescribing". METHOD: The method used was cluster randomized controlled design. All GPs working in six cities in one province in Iran were invited to participate. The cities were matched and randomly divided into an intervention arm for education on rational prescribing with an outcome-based approach, and a control arm for a traditional program on the same topic. Knowledge and skills were assessed using a pre- and post-test, including case scenarios. RESULTS: In total, 112 GPs participated. There were significant improvements in knowledge and prescribing skills after the training in the intervention arm as well as in comparison with the changes in the control arm. The overall intervention effect was 26 percentage units. CONCLUSION: The introduction of an outcome-based approach in CME appears to be effective when creating programs to improve GPs' knowledge and skills.

Interprofessional and problem-based learning: a marriage made in heaven?

This paper explores interprofessional learning (IPL) and whether it would profit from a more systematic merger with problem-based learning (PBL). IPL is based on the idea of bringing together knowledge from the different health professions as they interact with each other for better health care. PBL springs from the idea of bringing learning closer to the application of knowledge in every day life. It has been widely adopted as an interprofessional learning method, for example at Linkøping in Sweden.

Twenty years experiences of interprofessional education in Linkoping--ground-breaking and sustainable.

A pioneering and ground-breaking effort to organize interprofessional education (IPE) was initiated in 1986 at the Faculty of Health Sciences at Linkoping University in Sweden. The so-called "Linkoping IPE model" has now yielded practical experience and development of curricula for over 20 years. The basic idea of this model is that it is favorable for the development of students' own professional identity to meet other health and social professions already into their undergraduate studies. Interprofessional learning is a process over time that requires several integrated stages to gain interprofessional competence, i.e., the skills required to work together interprofessionally in practice. We believe that defined IPE modules early in the curriculum combined with student-training ward placement as the final module is an encouraging example of how to implement undergraduate IPE among health science students. It is strengthened by problem based learning (PBL) in small groups and student-centered learning. Based on these experiences, this paper aims to contribute to the discussion on how to implement and achieve the aims of IPE and to keep it sustainable. It is not a description of "how to do it" but rather a summarizing of our experiences for successful performance of IPE. The article presents how the Linkoping model was developed, the outcomes, experiences and some outlines for future challenges.

A comparison of experiences of training emergency care in military exercises and competences among conscript nurses with different levels of education.

The military emergency care education of nurses is primarily concerned with the treatment of soldiers with combat-related injuries. Even though great progress has been made in military medicine, there is still the pedagogical question of what emergency care education for military nurses should contain and how it should be taught. The aim of this study was to describe and compare experiences of training emergency care in military exercises among conscript nurses with different levels of education. A descriptive study was performed to describe and compare experiences of training emergency care in military exercises among conscript nurses with different levels of education in nursing. There were statistical differences between nurses with general nursing education and nurses with a general nursing education and supplementary education. A reasonable implication of the differences is that the curriculum must be designed differently depending on the educational background of the students. Hence, there is an interaction between background characteristics, e.g., the level of previous education and differences pertaining to clinical experience of the participants, and the impact of the exercise itself.

The criteria nurses use in assessing acute trauma in military emergency care.

Emergency medical care for seriously injured patients in war or warlike situations is highly important when it comes to soldiers' survival and morale. The Swedish Armed Forces sends nurses, who have limited experience of caring for injured personnel in the field, on a variety of international missions. The aim of this investigation was to identify the kind of criteria nurses rely on when assessing acute trauma and what factors are affecting the emergency care of injured soldiers. A phenomenographic research approach based on interviews was used. The database for the study consists of twelve nurses who served in Bosnia in 1994-1996. The criteria nurses rely on, when assessing acute trauma in emergency care, could be described in terms of domain-specific criteria such as a physiological, an anatomical, a causal and a holistic approach as well as contextual criteria such as being able to communicate, having a sense of belonging, the military environment, the conscript medical orderly and familiarity with health-caring activity. The present study shows that the specific contextual factors affecting emergency care in the field must also be practised before the nurse faces military emergency care situations. This calls for realistic exercises and training programs, where experience from civilian emergency care is interwoven with the knowledge specific to military medical care.

Changing Primary Care Doctors' Conceptions - A Qualitative Approach to Evaluating an Intervention.

Objective: To describe conceptions of the management of hyperlipidaemia and assess changes in conceptions after an educational intervention.- Setting and subjects: Primary care in Sweden. Twenty doctors at community health centres.- Methods: Within an educational experiment evaluating the effects of 'group detailing' by community pharmacists at 67 health centres, a selected sample of doctors were interviewed on two occasions, one and a half year apart, regarding their views on atherosclerotic cardiovascular disease and hyperlipidaemia. Half of the doctors had, in between the interviews, participated in four educational group sessions, where information was presented and discussed regarding the national recommendations on the management of hyperlipidaemia. Applying a phenomenographic approach, the variation of conceptions was described regarding six domains: general attitude to cardiovascular disease, risk factors, prevention of ischaemic heart disease, role of blood lipids, treatment of hyperlipidaemia, and screening for hypercholesterolaemia.- Outcome measures: Descriptions of categories of conceptions and changes of conceptions to ones in line with the treatment guidelines for individual doctors and for the two groups of doctors.- Results: There was a variation of conceptions in all six domains in both groups of doctors. The doctors' conceptions in the intervention group changed significantly to ones in line with the treatment recommendations (p < 0.01), which was not the case in the control group. A significant number of doctors in the intervention group changed at least one of the six conceptions to ones in concordance with the recommendations (p = 0.011). Although doctors in the control group also changed conceptions, this change was not statistically significant.- Conclusions: The doctors' conceptions changed significantly after 'group detailing' on management of hyperlipidaemia. Qualitative changes of conceptions may be used as outcome measures when evaluating the impact of an information activity directed at health care professionals.

Refusing to be ill: a longitudinal study of patients' experiences of asthma/allergy.

PURPOSE: The purpose of this study was to search for a deeper understanding of the ways patients with asthma/allergy experience their illness situation. METHOD: Thirty patients with a history of airway symptoms on allergen exposure and a positive skin prick test were included in the study. They took part in open-ended interviews in their homes twice at an interval of eight years, according to the phenomenographic approach. RESULTS: Fourteen different categories of experience were identified: 'knowing for oneself, 'body related', 'environment related', 'psychosomatic', 'magic', 'fatalism', 'compliance with medication', 'alternative medicine', 'health care', 'provocation', 'avoidance', 'normalization', 'normification' and 'pursuing life'. The analysis also showed that these categories, to varying degrees, were an expression of a desire to retain an ordinary healthy identity and its value. The longitudinal results showed that with time the patients distanced themselves from the medical perspective and found their own ways of thinking and acting in relation to their ill health, which is seen as strengthening for the identity. CONCLUSIONS: The different, individual ways patients with asthma/allergy developed in relation to the illness situation have a preserving effect on the identity, which ought to be considered in patient education and rehabilitation.

Parents' expectations about participating in antenatal parenthood education classes.

Our objective was to assess parents' expectations about participating in antenatal parenthood education classes and to determine whether their expectations might be related to gender, age, and educational level. Data from 1,117 women and 1,019 partners residing in three cities in Sweden were collected with a questionnaire in a cross-sectional study. Participants believed that antenatal education classes would help them to feel more secure as parents and to be better oriented toward childbirth. Men had more positive expectations about the childbirth than the women. The participants mostly wanted help in preparing for parenthood and in learning infant care skills, followed by help in preparing for childbirth. The participants' expectations were affected by gender, age, and educational level. The expectant parents appeared to want more focus on preparation for parenthood than on childbirth.

Interprofessional learning as a means of enhancing professional competence.

This paper explores some core features of interprofessional learning (IPL) and provides an example from the Swedish context. At Linköping university IPL was made an integral part of the problem based learning (PBL) programs that were implemented in 1986 at the Faculty of health sciences. A description of how the IPL strand is designed and some conclusions from evaluation studies are as well provided.

To be and to have a critical friend in medical teaching.

BACKGROUND: In order to stimulate reflection and continuous professional development, a model of critical friends evaluating each other was introduced in medical education. OBJECTIVE: To investigate whether the critical friend concept can serve as a pragmatic model for evaluation of medical teachers and as a fruitful tool for enhancing self-knowledge and professional development among medical educators. METHODS: Three pairs of critical friends were formed, consisting of experienced medical teachers (n = 6) at the Karolinska Institutet. Each teacher was assigned to give 1 lecture and 1 seminar in his or her specific research or clinical field. The critical friend evaluated the performance in class, acting as an observer using a pre-formed protocol. The evaluation was communicated to the teacher during a 45-minute session within 48 hours after the teaching session. Each of the 6 teachers was criticised and gave criticism within the pair configurance. The outcome of the process was evaluated by an experimenter, not participating in the process, who performed a semistructured interview with each of the 6 teachers. RESULTS: Each teacher had a different way of reflecting on teaching after the project than before and made changes in his or her way of teaching. We also noted that being a critical friend may be even more effective than having one. The majority of the feedback provided was positive and valuable. CONCLUSION: To be and to have a critical friend is worth the extra workload. Therefore, the critical friend concept should be made part of regular teaching practice.

Applying phenomenography in nursing research.

AIMS: This paper examines phenomenography, a research approach designed to answer certain questions about how people make sense of their experience. The research approach, developed within educational research, is a content-related approach investigating the different qualitative ways in which people make sense of the world around them. The outcomes of phenomenographic research are different content-related categories describing the differences in other people's ways of experiencing and conceiving their world. METHODS: The research approach is presented by describing the underlying ontological and epistemological assumptions, describing the research method in detail and providing some examples of phenomengraphic studies in health care and nursing research. The possibilities for applying the methodology to nursing research are discussed, illustrated by research examples. Finally, the future role of the approach within nursing research is discussed. CONCLUSION: The emphasis on differences in the phenomenographical research approach makes it distinct from other research approaches, and accordingly, it seems to be reasonable to incorporate knowledge of this kind in the professional education of health care personnel.