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Problems and Issues in Implementing Innovative Curriculum in the Developing countries: the Pakistani experience.
Background:
The Government of Pakistan identified 4 medical Colleges for introduction of COME, one from each province. Curriculum was prepared by the faculty of these colleges and launched in 2001 and despite concerted efforts could not be implemented. The purpose of this research was to identify the reasons for delay in implementation of the COME curriculum and to assess the understanding of the stakeholders about COME.
Methods:
Mixed methods study design was used for data collection. In-depth interviews, mail-in survey questionnaire, and focus group discussions were held with the representatives of federal and provincial governments, Principals of medical colleges, faculty and students of the designated colleges. Rigor was ensured through independent coding and triangulation of data.
Results:
The reasons for delay in implementation differed amongst the policy makers and faculty and included thematic issues at the institutional, programmatic and curricular level. Majority (92% of the faculty) felt that COME curriculum couldn't be implemented without adequate infrastructure. The administrators were willing to provide financial assistance, political support and better coordination and felt that COME could improve the overall health system of the country whereas the faculty did not agree to it.
Conclusion:
The paper discusses the reasons of delay based on findings and identifies the strategies for curriculum change in established institutions. The key issues identified in our study included frequent transfer of faculty of the designated colleges and perceived lack of* Continuation at the policy making level* Communication between the stakeholders* Effective leadership
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Experience with using second life for medical education in a family and community medicine education unit
Background:
The application of new technologies to the education of health professionals is both a challenge and a necessity. Virtual worlds are increasingly being explored as a support for education.Aim: The aim of this work is to study the suitability of Second Life (SL) as an educational tool for primary healthcare professionals.
Methods:
Design: Qualitative study of accredited clinical sessions in SL included in a continuing professional development (CPD) programme for primary healthcare professionals.Location: Zaragoza I Zone Family and Community Medicine Education Unit (EU) and 9 health centres operated by the Aragonese Health Service, Aragon, Spain.MethodThe EU held two training workshops in SL for 16 healthcare professionals from 9 health centres by means of two workshops, and requested them to facilitate clinical sessions in SL. Attendance was open to all personnel from the EU and the 9 health centres. After a trail period of clinical sessions held at 5 health centres between May and November 2010, the CPD-accredited clinical sessions were held at 9 health centres between February and April 2011.Participants: 76 healthcare professionals attended the CPD-accredited clinical sessions in SL.Main measurements: Questionnaire on completion of the clinical sessions.
Results:
Response rate: 42-100%. Questionnaire completed by each health centre on completion of the CPD-accredited clinical sessions: Access to SL: 2 centres were unable to gain access. Sound problems: 0% (0/9). Image problems: 0% (0/9). Voice/text chat: used in 100% (10/9); 0 incidents.Questionnaire completed by participants in the CPD-accredited clinical sessions: Preference for SL as a tool: 100% (76/76). Strengths of this method: 74% (56/76) considered it eliminated the need to travel; 68% (52/76) believed it made more effective use of educational resources; and 47% (36/76) considered it improved accessibility. Weaknesses: 91% (69/76) experienced technical problems, while; 9% (7/76) thought it was impersonal and with little interaction. 65.79% (50/76) believed it was better than other distance learning methods and 38.16% (29/76) believed it was better than face-to-face learning.
Conclusions:
SL is a tool that allows educational activities to be designed that involve a number of health centres in different geographical locations, consequently eliminating the need to travel and making more effective use of educational resources.
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Summative assessment of 5th year medical students' clinical reasoning by script concordance test: requirements and challenges
Background:
The Script Concordance Test (SCT) has not been reported in summative assessment of students across the multiple domains of a medical curriculum.Purpose: To report the steps used to build a test for summative assessment in a medical curriculum.
Methods:
A 51 case, 158-question, multidisciplinary paper was constructed to assess clinical reasoning in 5th-year. 10-16 experts in each of 7 discipline-based reference panels answered questions on-line. A multidisciplinary group considered reference panel data and data from a volunteer group of 6th Years, who sat the same test, to determine the passing score for the 5th Years.
Results:
The mean (SD) scores were 63.6 (7.6) and 68.6 (4.8) for the 6th Year (n=23, alpha = 0.78) and and 5th Year (n=132, alpha =0.62) groups (p<0.05), respectively. The passing score was set at 4 SD from the expert mean. Four students failed.
Conclusions:
The SCT may be a useful method to assess clinical reasoning in medical students in multidisciplinary summative assessments. Substantial investment in training of faculty and students and in the development of questions is required.
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Willingness to provide behavioral health recommendations: a cross-sectional study of entering medical students
Background:
Behavioral factors contribute importantly to morbidity and mortality, and physicians are trusted sources for information on reducing associated risks. Unfortunately, many clinical encounters do not include prevention counseling, and medical school curriculum plays an important role in training and promoting such counseling among medical students.
Methods:
We surveyed all 93 freshman medical students at entry to the University of California, Davis School of Medicine in 2009 to evaluate baseline knowledge of population health principles and examine their approach to clinical situations involving four common behavioral risk factors illustrated in brief clinical vignettes: smoking, alcohol use in a patient with indications of alcoholism, diet and exercise in an overweight sedentary patient, and a 16-year-old contemplating initiation of sexual intercourse. Based on vignette responses, we assessed willingness to (1) provide information on risks, (2) recommend elimination of the behavior as the most efficacious means for reducing risk, (3) include strategies apart from elimination of the behavior for lowering risk (i.e., harm reduction), and (4) assure of their intention to continue care whether or not recommendations are accepted.
Results:
Students answered correctly 71.4% (median; interquartile range 66.7% - 85.7%) of clinical prevention and population health knowledge questions; men scored higher than women (median 83.3% vs. 66.7%, p<0.02). Students showed high willingness to provide information and strategies for harm reduction apart from risk elimination, while respecting patient autonomy. Willingness to recommend elimination of high-risk behaviors "always or nearly always" was high for smoking (78.5%), alcohol consumption in a patient with indications of alcoholism (64.5%), and diet and exercise in a sedentary and overweight individual (87.1%), and low for the 16-year-old considering initiating sexual intercourse (28.0%; Friedman test, p<0.001). Willingness was not associated with the respondent's background knowledge of population health principles or gender.
Conclusion:
Students showed high willingness to educate and respect patient autonomy. There was high willingness to recommend elimination of risk behaviors for smoking, alcohol, and poor diet/exercise, but not for sexual intercourse in an adolescent considering sexual debut. Further research should address promoting appropriate science-based preventive health messages, and curriculum should include explicit discussion of content of recommendations.
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Dermatology undergraduate skin cancer training: a disconnect between recommendations, clinical exposure and competence
Background:
Skin cancers are the most common malignancies in Caucasian populations. Non-specialists are responsible for the initial assessment of skin lesions and are required to act as the gatekeepers to dermatological cancer services in many healthcare systems. The majority of such physicians receive very limited formal undergraduate or postgraduate dermatology training. The British Association of Dermatologists (BAD) has produced guidelines that list the lesions that students should be able to diagnose on graduation and the majority of UK medical schools' operate curricula in keeping with these. There is, however, virtually no evidence as to whether these competencies are being achieved. We set out to determine students' competence at skin lesion diagnosis and to quantify their clinical exposure to examples of such lesions during their dermatology attachment.
Methods:
Three linked studies were undertaken. In the first, students' competence was tested by randomized slideshows of images containing the 16 lesions recommended in the UK guidelines. Students' accuracy was tested at the beginning (Day-1) and end (Day-10) of their clinical placement, with a random sample of students retested 12 months later. Second, students' exposure to these lesions was recorded during their attachments. Finally a survey of the additional dermatological resources used by the students was undertaken.
Results:
Study 1: Students' diagnostic accuracy increased from 11% on Day-1 to 33% on Day-10 (effect size +2.72). After 12 months half of this effect had disappeared and the students accuracy had dropped to 24%. Study 2: Students' exposure to the recommended lesions was poor with 82% not even witnessing a single example of each of the 3 major skin cancers. Despite these measurements, only a minority of students reported that they were not confident at diagnosing skin tumours. Study 3: The majority of students use additional resources to supplement their learning.
Conclusions:
In the light of what we know about learning in dermatology our data would suggest that the current (traditional) undergraduate attachment is inadequate to meet the UK recommendations for graduate competence. As well as critically examining the basis for these recommendations, we need more empirical data on student performance and exposure, in order to improve teaching and learning.
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Peer observation of teaching as a faculty development tool
Background:
Peer observation of Teaching involves observers providing descriptive feedback to their peers on learning and teaching practice as a means to improve quality of teaching. This study employed and assessed peer observation as a constructive, developmental process for members of a Pediatric Teaching Faculty.MethodS This study describes how peer observation was implemented as part of a teaching faculty development program and how it was perceived by teachers. The PoT process was divided into 4 stages: pre-observation meeting, observation, post-observation feedback and reflection. Particular care was taken to ensure that teachers understood that the observation and feedback was a developmental and not an evaluative process. Twenty teachers had their teaching peer observed by trained Faculty members and gave an e-mail 'sound-bite' of their perceptions of the process. Teaching activities included lectures, problem-based learning, small group teaching, case-based teaching and ward-based teaching sessions.
Results:
Teachers were given detailed verbal and written feedback based on the observer's and students' observations. Teachers' perceptions were that PoT was useful and relevant to their teaching practice. Teachers valued receiving feedback and viewed PoT as an opportunity for insight and reflection. The process of PoT was viewed as non-threatening and teachers thought that PoT enhanced the quality of their teaching, promoted professional development and was critical for Faculty development.
Conclusions:
This study demonstrated that PoT can be used in a constructive way to improve course content and delivery, to support and encourage medical teachers, and to reinforce good teaching.
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The role of feedback in improving the effectiveness of workplace based assessments: A systematic review
Background:
Although there is considerable emphasis placed on workplace based assessment as a method of formative performance assessment, there is limited evidence in the current literature regarding the effectiveness of workplace based assessment in changing the behaviour of doctors and improving their performance. The aim of this systematic review is to elucidate the efficacy of feedback in improving the effectiveness of workplace based assessments in postgraduate medical training.
Methods:
Searches were conducted using the following bibliographic databases to identify original published studies related to WBA and the role of feedback: Medline (1950-December 2010), Embase (1980-December 2010) and Journals@Ovid (English language only, 1996-December 2010). Studies which attempted to evaluate the role of feedback in WBA (multi-source feedback, direct observation of procedural skills, mini-clinical evaluation exercise, procedure based assessment or case-based discussion) involving postgraduate doctors were included.
Results:
15 identified studies met the inclusion criteria and minimum quality threshold. They were heterogeneous in methodological design. 7 studies focussed on multi source feedback, 3 studies were based on mini-clinical evaluation exercise, 2 looked at procedural based assessment, one study looked at workplace based assessments in general and 2 studies looked at a combination of 3 to 6 workplace based assessments. 7 studies originated from the United Kingdom. Others were from Canada, the United States and New Zealand. Study populations were doctors in various grades of training from a wide range of specialties including general practice, general medicine, general surgery, dermatology, paediatrics and anaesthetics. All studies were prospective in design, and non-comparative descriptive or observational studies using a variety of methods including questionnaires, one to one interviews and focus groups.
Conclusions:
The evidence base contains few high quality conclusive studies and more studies are required to provide further evidence for the effect of feedback from workplace based assessment on subsequent performance. There is, however, good evidence that if well implemented, feedback from workplace based assessments, particularly multisource feedback, can be an effective and feasible way to support professional development.
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Does doctors' workload impact supervision and
ward activities of final-year students? A prospective
study
Background:
Hospital doctors face constantly increasing workloads. Besides caring for patients, their duties also comprise the education of future colleagues. The aim of this study was to objectively investigate whether the workload arising from increased patient care interferes with student supervision and is associated with more non-medical activities of final-year medical students.
Methods:
A total of 54 final-year students were asked to keep a diary of their daily activities over a three-week period at the beginning of their internship in Internal Medicine. Students categorized their activities - both medical and non-medical - according to whether they had:(1) only watched,(2) assisted the ward resident,(3) performed the activity themselves under supervision of the ward resident, or(4) performed the activity without supervision.The activities reported on a particular day were matched with a ward specific workload-index derived from the hospital information system, including the number of patients treated on the corresponding ward on that day, a correction factor according to the patient comorbidity complexity level (PCCL), and the number of admissions and discharges. Both students and ward residents were blinded to the study question.
Results:
A total of 32 dairies (59 %, 442 recorded working days) were handed back. Overall, the students reported 1.2 +/- 1.3 supervised, 1.8 +/-1.6 medical and 3.6 +/- 1.7 non-medical activities per day. The more supervised activities were reported, the more the number of reported medical activities increased (p < .0001). No relationship between the ward specific workload and number of medical activities could be shown.
Conclusion:
There was a significant association between ward doctors' supervision of students and the number of medical activities performed by medical students. The workload had no significant effect on supervision or the number of medical or non-medical activities of final-year students.
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Clinical capabilities of graduates of an outcomesbased
integrated medical program
Purpose: To evaluate perceived and assessed clinical capabilities of recent graduates of an outcomes-based integrated medical program and compare to benchmarks from traditional content-based or process-based programs.MethodSelf-perceived capability in a range of clinical tasks and assessment of medical education as preparation for hospital practice were evaluated in recent graduates after 3 months working as junior doctors. Responses of the 2009 graduates of the University of New South Wales' (UNSW) new outcomes-based integrated medical education program were compared to those of the 2007 graduates of UNSW's previous content-based program, to published data from other Australian medical schools, and to hospital-based supervisor evaluations of their clinical competence.
Results:
Three months into internship, graduates from UNSW's new outcomes-based program rated themselves to have good clinical and procedural skills, with ratings that indicated significantly greater capability than graduates of the previous UNSW content-based program. New program graduates rated themselves significantly more prepared for hospital practice in the confidence (reflective practice), prevention (social aspects of health), interpersonal skills (communication), and collaboration (teamwork) subscales than old program students, and significantly better or equivalent to published benchmarks of graduates from other Australian medical schools. Clinical supervisors rated new program graduates highly capable for teamwork, reflective practice and communication.
Conclusions:
Medical students from an outcomes-based integrated program graduate with excellent self-rated and supervisor-evaluated capabilities in a range of clinically-relevant outcomes. The program-wide curriculum reform at UNSW has had a major impact in developing capabilities in new graduates that are important for 21st century medical practice.
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Using video-cases to assess student reflection: Development and validation of an instrument
Background:
Reflection is a meta-cognitive process, characterized by: 1. Awareness of self and the situation; 2. Critical analysis and understanding of both self and the situation; 3. Development of new perspectives to inform future actions. Assessors can only access reflections indirectly through learners' verbal and/or written expressions. Being privy to the situation that triggered reflection could place reflective materials into context. Video-cases make that possible and, coupled with a scoring rubric, offer a reliable way of assessing reflection.
Methods:
Fourth and fifth year undergraduate medical students were shown two interactive video-cases and asked to reflect on this experience, guided by six standard questions. The quality of students' reflections were scored using a specially developed Student Assessment of Reflection Scoring rubric (StARS(R)). Reflection scores were analyzed concerning interrater reliability and ability to discriminate between students. Further, the intra-rater reliability and case specificity were estimated by means of a generalizability study with rating and case scenario as facets.
Results:
Reflection scores of 270 students ranged widely and interrater reliability was acceptable (Krippendorff's alpha = 0.88). The generalizability study suggested 3 or 4 cases were needed to obtain reliable ratings from 4th year students and > 6 cases from 5th year students.
Conclusion:
Use of StARS(R) to assess student reflections triggered by standardized video-cases had acceptable discriminative ability and reliability. We offer this practical method for assessing reflection summatively, and providing formative feedback in training situations.
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