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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., (© 2010, Copyright the Authors. Journal compilation © 2010, The American Geriatrics Society.)

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.

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.

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.

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.

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.

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.

Background: By some estimates, the teacher-learner relationship explains roughly half of the variance attributed to the effectiveness of teaching. Despite this, relationships largely have been ignored in the educational literature., Purpose: This qualitative pilot study sought to identify factors in the supervisor-resident relationship that hinder learning among University of Toronto psychiatry residents., Method: Thirteen postgraduate-year residents in Years 2-5 and their supervisors were interviewed regarding interactions that either assisted or adversely affected learning., Results: Qualitative analysis of the interview data led to the identification of 5 types of issues affecting the supervisory relationship: goals and individual differences, communication and feedback, power and rivalry, support and collegiality, and role modeling and expertise. Face validity was supported when typed anonymous written feedback obtained from annual supervisor evaluations also could be organized into the 5 categories., Conclusions: Recognition of the types of interpersonal interactions that assist or hinder learning may contribute to enhanced teaching effectiveness.

Background: The traditional remedies applied by medical schools to the perennial problem of teaching "caring competence" have been unsuccessful., Purpose: Our purpose was to design and evaluate a simple and effective method for helping students maintain affective contact with their patients., Methods: Third-year medical students and pediatric residents were given the opportunity to talk informally with parents of medically ill children and reflect on the value of this experience for their learning. Trainees' opinions of the experience were measured with focus groups and a questionnaire., Results: Trainees were delighted with the experience, particularly with the following aspects: the opportunity to hear a personally relevant story told in a sincere manner, the realization that they could have an authentic interaction "even" in a medical setting, and the usefulness of the information they derived from the conversation., Conclusions: We concluded that something unique to the conversational experience has educational value.

The beliefs that teachers hold about the appropriate roles and responsibilities of teachers shape the ways they teach and the ways they think about teaching. In this paper I describe four teaching roles based on a taxonomy that I've recently developed. Teachers who are guided primarily by the Content Expert Role view themselves as experts who serve as resources, like books or pictures. Teachers who are guided primarily by the Performance Role view themselves as agents who make learning happen by transmitting information or shaping students. Teachers guided primarily by the Interactive Role view themselves as guides who facilitate learning by interacting with learners. And teachers guided primarily by the Relational Role view themselves as engaged in relationships with learners for the purpose of helping them. Using examples taken from the health sciences I explain how each of the four teaching roles might succeed or fail depending upon the position that it occupies within a teaching-learning system. When teaching is viewed as part of a system, not as something a teacher does to a learner, teachers are successful if their particular contribution to the system is essential to the learning system. I also describe the process whereby teachers expand their belief system to include more roles. Such changes in belief systems are major shifts that qualify as "perspective transformations". Perspective transformations take place slowly and are typically attended by strong emotions. I end this paper with advice to teachers regarding ways they can harmonize with the educational system or face the challenge of perspective transformation.

The development and maintenance of expertise in any domain requires extensive, sustained practice of the necessary skills. However, the quantity of time spent is not the only factor in achieving expertise; the quality of this time is at least as important. The development and maintenance of expertise requires extensive time dedicated specifically to the improvement of skills, an activity termed deliberate practise. Unfortunately, determining how to engage in this deliberate practise is not obvious for tasks such as diagnosis, which involve high stakes and are predominantly cognitive nature. Reflection on and adaptation of one's cognitive processes is important; this could be supplanted by seeking out the opportunity to engage in trial and error in low risk environments such as simulators. Regardless, most individuals tend to favour well-entrenched activities and avoid practise. This may be due to lack of awareness of deficiencies in performance. However, it may also be due to the individual's conception of the nature of expertise. Although expertise requires experience, experience alone is insufficient. Rather, the development of expertise is critically dependent on the individual making the most of that experience. As a result, motivational factors are fundamental to the development of expertise. Overcoming deficiencies in self-monitoring is not a sufficient remedy. It is also necessary is that clinicians form an attitude toward work that includes continual re-investment in improvement.

Objective: To ensure uniform design and evaluation of a clerkship curriculum for child and adolescent psychiatry teaching common disorders and problems in an efficient manner across 5 teaching sites and to include structures for continuous improvement., Method: The curriculum committee selected for course inclusion disorders and problems of child psychiatry that were commonly encountered by primary care physicians. Instruction methods that encouraged active student learning were selected. Course coordination across sites was encouraged by several methods: involving faculty, adopting a centralized examination format, and aligning teaching methods with examination format. Quantitative and qualitative methods were used to measure students' perceptions of the course's value. These evaluative results were reviewed, and course modifications were implemented and reevaluated., Results: The average adjusted student return rate for course evaluation questionnaires for the 3-year study period was 63%. Clerks' ratings of course learning value demonstrated that the course improved significantly and continually across all sites, according to a Scheffé post-hoc analysis. Analysis of student statements from focus-group transcripts contributed to course modifications, such as the Brief Focused Interview (BFI)., Conclusions: Our curriculum in child psychiatry, which focused on common problems and used active learning methods, was viewed as a valuable learning experience by clinical clerks. Curriculum coordination across multiple teaching sites was accomplished by including faculty in the process and by using specific teaching and examination strategies. Structures for continuous course improvement were effective.

Purpose: To evaluate the effectiveness of binary content checklists in measuring increasing levels of clinical competence., Method: Fourteen clinical clerks, 14 family practice residents, and 14 family physicians participated in two 15-minute standardized patient interviews. An examiner rated each participant's performance using a binary content checklist and a global process rating. The participants provided a diagnosis two minutes into and at the end of the interview., Results: On global scales, the experienced clinicians scored significantly better than did the residents and clerks, but on checklists, the experienced clinicians scored significantly worse than did the residents and clerks. Diagnostic accuracy increased for all groups between the two-minute and 15-minute marks without significant differences between the groups., Conclusion: These findings are consistent with the hypothesis that binary checklists may not be valid measures of increasing clinical competence.

To evaluate whether feedback to medical students could be improved by asking teachers to complete a student performance rating form during a family practice clerkship, the authors had students and teachers fill out a questionnaire. Teachers in the intervention group reported observing students more frequently. Students' perceptions of feedback frequency correlated strongly with their ratings of feedback quality.

Teaching improvement workshops are most effective when they engage teachers actively in practice teaching, particularly when the teaching situation is similar to the actual one to which the teachers will return. Teachers, however, often find such involvement threatening. In this paper we describe a 3 h workshop which succeeds in overcoming teachers' reluctance to participate in situations that are relevant to their real teaching problems, students, and subject matter. The most exciting outcome, in our view, was teachers' increased sensitivity to the limitations of their teaching approach and their increased awareness of the role of their concept of teaching in shaping their teaching strategies. Weaknesses of the workshop include its dependence on the skills of a group director, the tendency of the group to seek a single right answer instead of exploring alternatives and the usual danger of role rigidity which troubles all role enactment procedures.

To detect any change in medical students' attitudes toward medical ethics, students from the same class were given a questionnaire on their first day of medical school and again near the end of their fourth year of study. The results showed a strong shift away from the students' initial expectations that they would rely on specialists or scholarly sources in the future; the need for a medical ethics course in the curriculum, while still felt, was less important to them by the fourth year. The reasons for these changes were not apparent, for the students' levels of knowledge and perceptions of the role of ethics in medicine in the first and fourth years did not differ. It is recommended that medical school faculty actively reinforce the initially positive attitudes of students during clinical supervision.

Three of the most widely used concepts in education, objectives, curriculum, and evaluation, have direct parallels in primary care. This parallelism suggests an approach which may help family physicians both in understanding these educational concepts and in applying them with judgment. By drawing specific attention to the parallels and by the use of examples drawn both from clinical practice and from teaching, the author hopes to encourage physicians to view their teaching as an analog of clinical skills that are already familiar to them. This approach is applied to the problem of accommodating to individual differences in students, the most difficult obstacle to the proper application of educational concepts.

In medical schools, most clinical teaching takes place in small groups in which the teacher and/or one of the students carry out the interview, examination or procedure, while one or more of the other members of the group looks on. Students, then, are as often watchers as doers. What do students learn from observing someone else doing something, and what can be done to enhance the effectiveness of this learning process? The authors attempted to answer these questions. They conducted an experimental study designed to evaluate student experience as observers. The data garnered from this study indicated that students regarded learning by observation as a useful, even valuable, experience. The data also suggested that the effectiveness of this learning experience was derived from a shared sense of immediate, emotionally charged, highly interactive participation in the proceedings, and that the teacher's catalytic function was essential to this process.

A survey of medical students on their first day of medical school and again near the end of their first year measured the discrepancy between their expectations of various aspects of the first year and their retrospective opinions about these aspects. The entering students had specific, detailed expectations about numerous aspects, many of which were not confirmed by their subsequent experience. The same students were reminded, one year later, of their unfulfilled expectations about the first year and were asked to describe any effects these expectations had had on class emotional climate and morale. They recalled both serious disappointments and pleasant surprises but no general change of class morale. A serendipitous finding was the profound indifference of the second-year students to their first-year emotional responses. Our results challenge the general practice of basing curriculum renewal programs on cross-sectional student surveys with no consideration of baseline expectations, and of relying on students to initiate improvements in educational programs.