Is it science? A study of the attitudes of medical trainees and physicians toward qualitative and quantitative research.

This study examined the degree of acceptance of qualitative research by medical trainees and physicians, and explored the causes for any differences in their support of qualitative versus quantitative research. Thirty-two individuals at four levels of medical training were studied. Eight philosophers of science served for construct validation. After completing a questionnaire, participants were interviewed using a semi-structured procedure. Transcriptions of the interviews were coded for emergent themes. Coding consensus was achieved via iterative discussion. When asked to categorize 10 projects, participants on average ranked quantitative science projects as "more scientific" than those using qualitative methodologies. Although participants appeared largely unaware of the principles underlying qualitative methodologies, most expressed the belief that qualitative data was more biased and less objective than quantitative data. Prior qualitative research experience was the major predictor of acceptance of qualitative research. Participants' acceptance of interpretivistic or positivistic paradigms also influenced what type of science they felt was acceptable. Their level of training did not correlate with the acceptance of qualitative methodologies. On average, participants in our study favoured quantitative methodologies over qualitative methodologies. We postulate that this preference is due to their unawareness of the principles and paradigms underlying the methodologies.

Creating effective learning in today's emergency departments: how accomplished teachers get it done.

STUDY OBJECTIVES: Significant impediments to effective emergency department (ED) teaching compromise what could otherwise be an excellent learning milieu. There is little literature to guide faculty development around specific emergency medicine teaching techniques. We determine what recognized experts in emergency medicine teaching consider to be the important clinical teaching behaviors that make them good teachers, the main impediments to good teaching in EDs, and important prerequisites for a good ED teacher. METHODS: This was a structured telephone survey with qualitative grounded-theory analysis. Participants were current Canadian emergency medicine teaching faculty who have won awards, been promoted, or received persistent excellent evaluations according to their ED teaching. Participants underwent a 45- to 60-minute standardized structured telephone interview. Interviews were transcribed and independently coded by 2 investigators using a grounded-theory approach. The codes were merged by consensus, and the data were recoded. Twenty percent of data were then coded by both investigators to estimate interrater reliability of final coding. Discrepancies were resolved by agreement. RESULTS: Of 43 potential participants, 33 were still in practice, available, and willing to participate. Twelve ED-specific, practical, implementable strategies representing the general themes of learner-centeredness, active learning, individual relevance, and efficiency emerged. Participants collectively identified 6 significant impediments to teaching and 9 prerequisites to being an effective ED teacher. CONCLUSION: Accomplished emergency medicine teaching faculty identify with common impediments to ED teaching yet are able to describe practical, easily implemented strategies that they believe make them good teachers. They also take advantage of basic prerequisites for good teaching.

Medical student perspectives on geriatrics and geriatric education.

OBJECTIVE: To ascertain medical students' perspectives on geriatrics. DESIGN: Interpretative phenomenological analysis. SETTING: An allopathic, Liaison Committee on Medical Education-accredited, former Donald W. Reynolds Foundation grant recipient, U.S. medical school. PARTICIPANTS: Thirty fourth-year medical students who completed geriatric educational activities in all 4 years of medical school. MEASUREMENTS: Two researchers independently reviewed verbatim transcripts from five focus groups and identified themes using the constant comparative method. RESULTS: Seventeen themes that elaborate on students' perspectives on geriatrics were identified. Students reported not feeling appropriately engaged in geriatrics, despaired at the futility of care, were depressed by the decline and death of their patients, were frustrated by low reimbursement rates and low prestige despite fellowship training, were concerned about patients' unrealistic expectations and opportunities for litigation, felt unsure how to handle ethical dilemmas, and found communicating with older adults to be enjoyable but time consuming and challenging. They felt they had too much exposure to geriatrics in medical school. CONCLUSION: Current attitude scales fail to capture some of the dimensions uncovered in this study, whereas students did not mention other dimensions commonly included in attitude scales. Regarding curriculum development, students may find an integrated preclinical geriatric curriculum to be more relevant to their careers than a stand-alone curriculum. Clinical clerkships might be in a better position to emphasize the positive aspects of geriatrics and develop strategies to address students' negative attitudes.

What do emergency medicine learners want from their teachers? A multicenter focus group analysis.

BACKGROUND: To the best of the authors' knowledge, there are no reports describing what learners believe are good emergency medicine (EM) teaching practices. EM faculty developers are compromised by this lack of knowledge about what EM learners appreciate in their teachers. OBJECTIVES: To determine what Canadian EM learners consider to be good prerequisites and strategies for effective teaching in the emergency department (ED). METHODS: Clinical clerks and residents from the Canadian College of Family Physicians, Emergency Medicine certification [CCFP(EM)] fellowship program, the Royal College of Physicians and Surgeons of Canada, Emergency Medicine certification [FRCP(EM)] fellowship program, and off-service programs from all five Ontario medical schools participated in monitored focus-group sessions. Conversations were recorded, transcribed by a third party, and coded by two independent assessors using standard grounded theory methods. The text was categorized based on the final code into basic themes and specific qualifiers, which were then sorted by frequency of mention in the focus groups. Results are presented in descriptive fashion. RESULTS: Twenty-eight learners participated. They identified 14 major principles for good EM teaching, and a further 30 specific qualifiers. The top five principles were: "has a positive teacher attitude," "takes time to teach," "uses teachable moments well," "tailors teaching to the learner," and "gives appropriate feedback." Agreement on classification of ideas was 86%. CONCLUSIONS: Learners are sensitive to the constraints of the ED teaching environment, and have consistent views about good ED teaching practices. Among 14 general principles identified, "takes time to teach," "gives feedback," "tailors teaching to the learner," "uses teachable moments," and "has a good teacher attitude" were the most commonly reported.

Teaching and learning medical ethics.

Three main questions are central to teaching and learning medical ethics. Can ethics be taught? If it can, what are some of its teachable components? And what teaching methods are appropriate? The author supports the concept of ethical competence as the basis of an ethical practice. Ethical competence is a set of insights, skills, understandings, ways of thinking which can be taught. The parallel is drawn between these kinds of competencies and the components of rigorous thinking characteristic of the training and experience of medical problem-solvers. Finally the author takes up four common criticisms of this approach.

Medical ethics in the next 25 years.

In the next 10-15 years most of the major ethical dilemmas facing family physicians will grow more acute. This is not to imply that things are getting worse. On the contrary, it is the simultaneous growth of miraculous methods and frightening risks that will make the dilemmas more acute. In the next 15-25 years, we will learn how to minimize the risks. Several major ethical dilemmas of medical practice are reviewed from this perspective. Finally, some issues are considered that do not fit this pattern and that have the potential to become a much greater challenge to humanity.

Community psychiatrists who see geriatric patients: what's training got to do with it?

OBJECTIVE: This study examines the issues influencing psychiatrists' decisions to provide care to the under-served geriatric population. METHODS: Community-based psychiatrists who see geriatric patients participated in focus group discussions exploring factors that influence the characteristics of their current practices. RESULTS: Personal themes, environmental issues and quality of residency training emerged as important factors interacting in eventual practice choice. Major influences within training programs included teachers, diverse patient exposure and high-quality essential skills teaching. CONCLUSION: Residency program curricula might capitalize on these to better prepare residents and enhance the likelihood of graduates eventually choosing to incorporate geriatric patients into their practices.

Adolescent standardized patients: method of selection and assessment of benefits and risks.

BACKGROUND: Our psychiatric Objective Structured Clinical Examination (OSCE) group wishes to develop adolescent psychiatry OSCE stations. The literature regarding adolescent standardized patient (SP) selection methods and simulation effects, however, offered limited assurance that such adolescents would not experience adverse simulation effects. PURPOSE: Evaluation of adolescent SP selection methods and simulation effects for low- and high-stress roles. METHOD: A two-component (employment-psychological) SP selection method was used. Carefully selected SPs were assigned across three conditions: low-stress medical role, high-stress psychosocial role, and wait list control. Qualitative and quantitative measures were used to assess simulation effects. RESULTS: Our selection method excluded 21% (7% employment and 14% psychological) of SP applicants. For SP participants, beneficial effects included acquisition of job skills and satisfaction in making an important contribution to society. SP reactions of discomfort to roles were reported. Long-term adverse effects were not identified. CONCLUSIONS: A two-component adolescent SP selection method is recommended. Adolescent SP benefits outweigh risks.

The challenge of creating new OSCE measures to capture the characteristics of expertise.

PURPOSE: Although expert clinicians approach interviewing in a different manner than novices, OSCE measures have not traditionally been designed to take into account levels of expertise. Creating better OSCE measures requires an understanding of how the interviewing style of experts differs objectively from novices. METHODS: Fourteen clinical clerks, 14 family practice residents and 14 family physicians were videotaped during 2 15-minute standardized patient interviews. Videotapes were reviewed and every utterance coded by type including questions, empathic comments, giving information, summary statements and articulated transitions. Utterances were plotted over time and examined for characteristic patterns related to level of expertise. RESULTS: The mean number of utterances exceeded one every 10 s for all groups. The largest proportion was questions, ranging from 76% of utterances for clerks to 67% for experts. One third of total utterances consisted of a group of 'low frequency' types, including empathic comments, information giving and summary statements. The topic was changed often by all groups. While utterance type over time appeared to show characteristic patterns reflective of expertise, the differences were not robust. Only the pattern of use of summary statements was statistically different between groups (P < 0.05). CONCLUSIONS: Measures that are sensitive to the nature of expertise, including the sequence and organisation of questions, should be used to supplement OSCE checklists that simply count questions. Specifically, information giving, empathic comments and summary statements that occupy a third of expert interviews should be credited. However, while there appear to be patterns of utterances that characterise levels of expertise, in this study these patterns were subtle and not amenable to counting and classification.