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Context: Institutional interactions are often asymmetrical in that the professional has more control over the conversation. It is difficult to say who the professional is in simulated consultations between simulated patients (SPs) and medical students because these feature a real (educational) institutional context and a simulated (medical) institutional context. This study describes this asymmetry and makes educational recommendations based on the description., Methods: One hundred assessed conversations between SPs and Year 3 students were transcribed and analysed using discourse analysis (DA). We aimed to find linguistic patterns in predefined parts of the conversations (questions, topic initiations, openings, closings) that might suggest conversational dominance., Results: The SP is conversationally more dominant, despite performing the role of the patient, in that he or she asks more direct questions, is more likely to initiate topics, is more likely not to follow topic changes by students, and closes the consultation. The student is likely to follow topics initiated by the SP and to seek permission to pre-close the consultation., Conclusions: The apparently greater dominance of the SP indicates that the simulated consultation differs from the doctor-patient consultation in certain key aspects. It is in that sense unrealistic. We argue, however, that 'realism' ought not to be a goal of simulated consultation and that what matters is that such consultations are sufficiently realistic for their educational purpose. We discuss the educational implications that follow from this., (© Blackwell Publishing Ltd 2013.)

Objectives: This study represents an initial evaluation of the first year (F1) of the Foundation Assessment Programme (FAP), in line with Postgraduate Medical Education and Training Board (PMETB) assessment principles., Methods: Descriptive analyses were undertaken for total number of encounters, assessors and trainees, mean number of assessments per trainee, mean number of assessments per assessor, time taken for the assessments, mean score and standard deviation for each method. Reliability was estimated using generalisability coefficients. Pearson correlations were used to explore relationships between instruments. The study sample included 3640 F1 trainees from 10 English deaneries., Results: A total of 2929 trainees submitted at least one of all four methods. A mean of 16.6 case-focused assessments were submitted per F1 trainee. Based on a return per trainee of six of each of the case-focused assessments, and eight assessors for multi-source feedback, 95% confidence intervals (CIs) ranged between 0.4 and 0.48. The estimated time required for this is 9 hours per trainee per year. Scores increased over time for all instruments and correlations between methods were in keeping with their intended focus of assessment, providing evidence of validity., Conclusions: The FAP is feasible and achieves acceptable reliability. There is some evidence to support its validity. Collated assessment data should form part of the evidence considered for selection and career progression decisions although work is needed to further develop the FAP. It is in any case of critical importance for the profession's accountability to the public.

Objectives: This study set out to answer the following questions. What influences a junior doctor's response to a judgement call within a clinical setting? What, if any, are the relationships between these influences?, Methods: This paper describes an interpretivist study based on a grounded theory approach to data analysis. This involved a phased approach to data collection using semi-structured interviews. Analysis was facilitated by observations and group presentations. Participants were doctors in their first year of postgraduate practice who were purposively selected from a range of hospitals in the Northern Deanery., Results: The data demonstrated a number of influences on whether junior doctors chose to seek senior assistance. These included the upholding and balancing of tenets that were necessary for ensuring safe practice, and estimating the chance and severity of potential negative consequences to patients, themselves and their teams. In order to make these judgements, junior doctors drew on different forms of knowledge, especially knowledge gained from previous clinical experiences. In judging whether or not to contact a senior, pre-registration house officers (PRHOs) were practising essential clinical attributes, that of independent yet co-operative and discerning practitioners who are able to balance multiple considerations while ensuring patient care., Conclusions: This particular judgement of risk, as it was described by those interviewed, was a dynamic process exemplified by the need to create counterbalances between multiple consequences. As a result, no prescriptive action could have allowed PRHOs to deal with the numerous configurations they faced and took into account.

Context: The challenges of maintaining comprehensive banks of valid checklists make context-specific checklists for assessment of clinical procedural skills problematic., Objectives: This paper reports the development of a tool which supports generic holistic assessment of clinical procedural skills., Methods: We carried out a literature review, focus groups and non-participant observation of assessments with interview of participants, participant evaluation of a pilot objective structured clinical examination (OSCE), a national modified Delphi study with prior definitions of consensus and an OSCE. Participants were volunteers from a large acute teaching trust, a teaching primary care trust and a national sample of National Health Service staff. Results In total, 86 students, trainees and staff took part in the focus groups, observation of assessments and pilot OSCE, 252 in the Delphi study and 46 candidates and 50 assessors in the final OSCE. We developed a prototype tool with 5 broad categories amongst which were distributed 38 component competencies. There was > 70% agreement (our prior definition of consensus) at the first round of the Delphi study for inclusion of all categories and themes and no consensus for inclusion of additional categories or themes. Generalisability was 0.76. An OSCE based on the instrument has a predicted reliability of 0.79 with 12 stations and 1 assessor per station or 10 stations and 2 assessors per station., Conclusions: This clinical procedural skills assessment tool enables reliable assessment and has content and face validity for the assessment of clinical procedural skills. We have designated it the Leicester Clinical Procedure Assessment Tool (LCAT).

Objective: This study sought to determine the relative contributions made by transferable skills and content-specific skills to Year 2 medical student performance in a clinical skills examination., Methods: Correlated trait-correlated method models were constructed to describe the performance of 2 year groups of students in examinations held in the summers of 2004 and 2005 at Peninsula Medical School in the UK. The transferable skills components of the models were then removed to indicate the contribution made to the fit of the models to the data., Results: Although content-specific skills made the greater contribution to the 2 models of student performance (accounting for averages of 54% and 43% of the variance, respectively), transferable skills did make an important but smaller contribution (averages of 13% and 16%, respectively). When the transferable skills components of the models were removed, the fit was not as good., Conclusions: Both content-specific skills and transferable skills contributed to performance in the clinical skills examination. This challenges current thinking and has important implications, not just for those involved in clinical skills examinations, but for all medical educators.

Context: Workload pressures may lead pre-registration house officers (PRHOs) to undervalue critical appraisal and thinking skills. This study aimed to explore Mersey Deanery PRHOs' attitudes, experiences and perceived readiness for practising evidence-based medicine with critical appraisal skills., Methods: A cross-sectional survey of 157 PRHOs from 5 postgraduate centres in the UK, using a semistructured questionnaire, at the beginning and end of the pre-registration year. Main outcome measures were level of agreement with closed statements exploring experiences and opinions about critical appraisal skills and evidence-based practice. Open questions explored personal experiences., Results: Most PRHOs (69%) felt medical school prepared them to use critical appraisal skills and perceived such skills as relevant (63%). Fewer felt that their clinical work was based on best available evidence (57%). The busier the PRHOs, the less likely they were to agree that their practice followed best evidence. The PRHOs were more likely to feel supported and that their practice was evidence-based at the end of the year. Responders identified several reasons for their practice not being evidence-based, including workload, lack of skills, deferring to senior colleagues, and non-conducive hospital culture., Conclusions: The nature of PRHO work still mitigates against critical thinking and appraising evidence, with a lack of protected time and perceived inconsistent support from educational supervisors. Many PRHOs rely entirely on evidence-based summaries and guidelines from others. The PRHO year is a period of crucial transition, however, and critical appraisal skills and evidence-based approaches need developing post-qualification, with sufficient protected time for their integration into practice. Foundation year reforms reinforce such requirements.

Objective: To explore junior medical students' notions of a 'good doctor', given their ideas about: success in Year 1, house jobs, and their attraction to medicine., Methods: Study participants were junior medical students (1999 and 2001 entry cohorts studied thrice and twice, respectively) and prospective students of the University of Liverpool's 5-year, problem-based, community-orientated curriculum. Data collection and analysis used a 'mixed methods' approach, cross-sectional design, and brief questionnaire surveys. In an index survey, open questions (analysed inductively) explored house jobs and Year 1 success. They also generated 'good doctor' themes, which a second survey confirmed and 3 surveys ranked. A sixth survey explored motivation for choosing medicine (open question). Good doctor rankings were analysed by postcode for prospective medical students classified as school-leaver residents of England and Wales., Results: Response rates were: 91.4% (973) of the 2001-02 admission candidates, on interview days; 68.0% (155), 61.2% (137) and 77.9% (159) of the 1999 cohort (at entry, end-Year 1 and mid-Year 3, respectively), and 71.0% (201) and 71.0% (198) of the 2001 cohort (at entry and end-Year 1, respectively). From 9 themes generally compatible with self-reported motivations and expectations, junior and prospective medical students consistently valued a good doctor as a 'compassionate, patient-centred carer' and a 'listening, informative communicator' over an 'exemplary, responsible professional'. Prospective students from less affluent English and Welsh postcodes valued 'efficient, organised self-manager' very slightly more highly (r(s) = - 0.140, P = 0.003)., Conclusions: This research provided empirical evidence to support ongoing commentary about patients mostly seeking qualities related to communication, caring, and competence in doctors. Weak evidence that socio-economic status might affect notions of a good doctor is worth pursuing.

Context: Self-assessment promotes reflective practice, helps students identify gaps in their learning and is used in curricular evaluations. Currently, there is a dearth of validated self-assessment tools in rheumatology. We present a new musculoskeletal self-assessment tool (MSAT) that allows students to assess their confidence in their skills in and knowledge of knee and shoulder examination., Objectives: We aimed to validate the 15-item MSAT, addressing its construct validity, internal consistency, responsiveness, repeatability and relationship with competence., Methods: Participants were 241 Year 3 students in Newcastle upon Tyne and 113 Year 3 students at University College London, who were starting their musculoskeletal skills placement. Factor analysis explored the construct validity of the MSAT; Cronbach's alpha assessed its internal consistency; standardised response mean (SRM) evaluated its responsiveness, and test-retest, before and after a pathology lecture, assessed its repeatability. Its relationship with competence was explored by evaluating its correlation with shoulder and knee objective structured clinical examinations (OSCEs). Results The MSAT was valid in distinguishing the 5 domains it intended to measure: clinical examination of the knee; clinical examination of the shoulder; clinical anatomy of the knee and shoulder; history taking, and generic musculoskeletal anatomical and clinical terms. It was internally consistent (alpha = 0.93), responsive (SRM 0.6 in Newcastle and 2.2 in London) and repeatable (intraclass correlation coefficient 0.97). Correlations between MSAT scores and OSCE scores were weak (r < 0.2)., Conclusions: The MSAT has strong psychometric properties, thereby offering a valid approach to evaluating the self-assessment of confidence in examination skills by students. Confidence does not necessarily reflect competence; future research should clarify what underpins confidence.

Objectives: Educational theory suggests that lectures may not be the best way to impart knowledge to students. The aim of this study was to compare the use of didactic lectures with that of interactive discussion sessions in undergraduate teaching of orthopaedics and trauma., Methods: A total of 77 medical students were assessed in 3 consecutive cohorts. The students were randomised into 2 groups. The first group received a series of 12 formal lectures. The second group covered the same topics in 12 group-discussion sessions with self-directed learning., Results: The students in the interactive discussion group rated the presentation of their teaching more highly than those in the lecture group (P = 0.003). However, there was no difference in their rating of the content of the sessions. The students in the discussion group also performed better on their end-of-placement written test (P = 0.025)., Conclusions: We found that interactive teaching styles are more popular than didactic lectures in undergraduate orthopaedic and trauma teaching. We also found some evidence that knowledge retention is better following an interactive teaching style.

Objective: To determine the risk factors for poor performance at different stages of the undergraduate medical course., Design: Longitudinal retrospective cohort study of progress on a 5-year undergraduate medical course., Setting: The University of Nottingham medical school., Participants: All students (594) who joined the course in 3 consecutive years were followed throughout their course until graduation, even if this was delayed., Results: Risk factors for poor performance varied at different stages on the course. Students with lower A levels were at increased risk throughout, but primarily in the pre-clinical course. Non-white ethnicity was also a risk factor, independent of domicile, but this was associated more strongly with lower marks on the clinical course. Males and those who received a later offer of a place were at some risk throughout the course. Overall attrition from the course was 5%, and 34/594 students (6%) spent more than the normal 5 years on the course., Conclusion: School performance remains an important indicator of ability to cope with the pre-clinical course. Further research is required to understand why ethnic minority students may be more at risk at all stages, but particularly in the clinical course, and to increase their use of existing support services if necessary.

Introduction: This paper seeks to describe the consultation strengths and weaknesses of senior medical students, the explicit and prioritised strategies for improvement utilised in student feedback, and curriculum developments informed by this work., Methods: Prospective, descriptive study of students on clinical placements in general practice. All were observed directly by 2 assessors in consultation with 5 patients in a general practice setting. Performance was judged against 5 categories of consultation competence and 35 component competences as contained in a modified version of the Leicester Assessment Package. Specific strategies for improvement were selected from a list of 69 previously formulated strategies., Results: Data from 1116 students were included. The consultation competences identified most frequently as strengths related to interpersonal skills, while weaknesses were mainly in the domain of clinical problem-solving. The median number of key strengths identified per student was 5, with 5 additional but lesser strengths. A median of 3 key and lesser weaknesses were identified. The average number of strategies selected to address an identified weakness was 1.2. Students rated the assessment process and its impact very positively., Conclusion: The systematic assessment of the consultation competence of medical students by direct observation involving real patients is feasible and facilitates the 'educational diagnosis' of individuals and of their peer group. It has informed development of teaching and generated research hypotheses.

Background: Multidisciplinary and interprofessional working is currently a priority in health care policy, in caring for patients and in health professional education. Realising multidisciplinary approaches presents challenges in the context of changes in doctors' and nurses' roles and the increased emphasis placed on communication with patients. In communication in consultations, explanations are employed in the service of numerous activities, including decision making, diagnosis and physical examination, but they have been little studied., Setting: This paper presents findings from a comparative study of doctors' and nurses' communication with patients in multidisciplinary health care, focusing on diabetes in primary care., Methods: Video- and audio-recorded consultations were subjected to conversation analysis. Output from discussion groups with patient representatives and health professionals underwent qualitative analysis., Findings: Distinctive features of explanations in nurses' and doctors' consultations with patients were identified. These can be understood by reference to patterns of communication. Nurses' communication was mediated by patients' contributions; doctors' communication gave an overarching direction to the consultation as a whole. While nurses' explanations began from the viewpoint of a patient's responsibility and behaviour, doctors' explanations began from the viewpoint of biomedical intervention. Their consultations lent different opportunities for patients' involvement., Conclusion: Nurses' and doctors' communications each exhibit their own distinct features. Specification of these features, when considered in the context of a particular consultation activity such as explanations, allows both recognition of the distinct contributions each profession can offer and identification of ways of combining these to maximum effect. This has implications for policy, for practice and for interprofessional education.

Background: Recommendations for medical training have seen a growing drive for undergraduate teaching to take place within the community - primarily in the general practice surgery. In light of the ongoing expansion of medical student numbers, many more general practices will be required to participate in undergraduate teaching., Aim: To explore the perceptions of primary care staff on the impact that increasing student numbers will have on them, on their patients and on the students themselves., Design of Study: Semi-structured interviews., Setting: Three general practices presently involved in undergraduate teaching, 3 practices about to become involved in undergraduate teaching and 1 non-teaching practice, all in the Black Country area of the West Midlands., Methods: Semi-structured interviews with prearranged prompts were undertaken with a variety of practice staff including general practitioners (GPs), practice managers and practice nurses, as well as administrative and reception staff., Results: Eleven GPs, 6 practice managers, 4 practice nurses and 6 receptionists/administrators took part in the interviews. Three main themes emerged relating to the effects on students and reflecting attitudes towards the Black Country, the experience of working among deprived populations and issues around access to the new training locations. The majority of interviewees were of the opinion that patients both enjoy taking part in undergraduate teaching and are able to benefit from the process. Positive impacts on practice infrastructure were also elicited, but when asked about the resource implications for the practice of undergraduate teaching, there was a dichotomy of opinion., Conclusion: For many practices, involvement in undergraduate teaching is a double-edged sword.

Aim: To explore the evaluation of self-directed, integrated clinical education., Methods: We delivered a quantitative and qualitative, self-report questionnaire to students through their web-based learning management system. The questionnaire was distributed 4 times over 1 year, each time in 2 parts. A generic part evaluated boundary conditions for learning, teaching activities and "real patient learning". Factor analysis with varimax rotation was used to validate the constructs that made up the scale and to stimulate hypotheses about how they interrelated. A module-specific part evaluated real patient learning of the subject matter in the curriculum., Results: A total of 101 students gave 380 of a possible 404 responses (94%). The generic data loaded onto 4 factors, corresponding to: firm quality; hospital-based teaching and learning; community and out-patient learning, and problem-based learning (PBL). A 5-item quality index had content, construct and criterion validity. Quality differed greatly between firms. Self-evaluation of module-specific, real patient learning was also valid. It was strongly influenced by the specialty interests of hospital firms., Conclusions: Quality is a multidimensional construct. Self-report evaluation of real patient learning is feasible, and could be capitalised on to promote reflective self-direction. The social and material context of learning is an important dimension of educational quality.

Background: Anatomy learning is generally seen as essential to medicine, and exposure to cadavers is generally seen as essential to anatomy learning around the world. Few voices dissenting from these propositions can be identified., Aims: This paper aims to consider arguments relating to the use of cadavers in anatomy teaching, and to describe the rationale behind the decision of a new UK medical school not to use cadaveric material., Discussion: First, the background to use of cadavers in anatomy learning is explored, and some general educational principles are explored. Next, arguments for the use of human cadaveric material are summarised. Then, possible arguments against use of cadavers, including educational principles as well as costs, hazards and practicality, are considered. These are much less well explored in the existing literature. Next, the rationale behind the decision of a new UK medical school not to use cadaveric material is indicated, and the programme of anatomy teaching to be employed in the absence of the use of human remains is described. Curriculum design and development, and evaluation procedures, are briefly described. Issues surrounding pathology training by autopsy, and postgraduate training in surgical anatomy, are not addressed in this paper., Future Directions: Evidence relating to the effect on medical learning by students not exposed to cadavers is scant, and plainly opportunities will now arise through our programme to gather such evidence. We anticipate that this discussion paper will contribute to an ongoing debate, in which virtually all previous papers on this topic have concluded that use of cadavers is essential to medical learning.

Aim: To investigate possible bias due to gender combination of students, role players and examiners in a high-stakes assessment., Setting: Valid oral interactive contextualized examinations (VOICEs) is a long-station OSCE-style exam in general practice (GP). At the time of writing it consisted of 65% of the student's final GP mark., Method: In the VOICE, students undertake six tasks--four vivas and two role-plays. "Patient" roles are taken by professional role players who work regularly on the undergraduate curriculum. During the role-play, the student's clinical competence is assessed by an observing GP examiner. The communication skills marks are awarded by the role player and the examiner together, by negotiation. Data have been recorded detailing the role player's initial marks, the examiner's initial marks and their final (awarded) agreed marks for 1024 consultations., Sample: 512 final year medical students, 28 role players and 48 examiners. There were no inclusion or exclusion criteria. All those present on exam day became part of the data., Results: There was a significant relationship between gender and performance for some, but not all, stations. Correlations for multiple comparisons removed the significance. Female students perform better across the board than male students. While not always significant, this did affect grading. There was no significant association between the genders of role players and examiners with the question choices. There has been a significant worsening of male results since 1999. Differences exist in the way that pairs of mixed or single genders score students.

Background: Portfolios are increasingly advocated in medical education. Qualitative studies have suggested their value in stimulating experiential learning, promoting deep learning and encouraging reflection. This study explored the use of educational portfolios in reflective learning by general practice (GP) registrars in Yorkshire, England., Method: A postal questionnaire was sent to the 92 registrars of a deanery in November 2001, after a pilot study with registrars in a single district had been carried out. The questionnaire explored the registrars' use of the portfolio to collect information and for reflection, as well as registrars' attitudes towards the portfolio. It was returned by 71 registrars, representing a 77% response rate. Structured in-depth interviews were used to support the results obtained., Results: Of the registrars who responded, 65% recorded information on a regular basis and 42% used the portfolio in reflective learning. Experienced registrars used the portfolio least. Those with supportive trainers used the portfolio more in reflection., Conclusions: The study suggests that the role of the trainer/supervisor is vital in portfolio-based learning. It raises questions about the acceptability of portfolio learning. It adds weight to the suggestion that careful introduction of portfolios and training of supervisors is vital. Further work to establish the role of portfolios in reflective learning is recommended.

Objective: To describe the perceptions of medical students and clinical teachers of teaching and learning in the clinical setting., Design: Qualitative study of focus groups with undergraduate medical students and semistructured interviews with hospital consultant clinical teachers., Setting: The School of Medicine, University of Leeds and the Leeds Teaching Hospitals Trust, UK., Participants: Fourth year medical students and consultant clinical teachers., Main Outcome Measures: Analysis of narratives to identify students' perceptions of clinical teaching and consultants' views of their delivery of undergraduate clinical teaching., Results: Students believed in the importance of consultant teaching and saw consultants as role models. However, they perceived variability in the quality and reliability of teaching between physicians and surgeons. Some traditional teaching venues, especially theatre, are believed to be of little clinical importance. Generally, consultants enjoyed teaching but felt under severe pressure from other commitments. They taught in a range of settings and used various teaching strategies, not all of which were perceived to be 'teaching' by students., Conclusions: While students and teachers are educational partners, they are not always in agreement about the quality, quantity, style or appropriate setting of clinical teaching. To enable teachers to provide more high quality teaching, there needs to be support, opportunities and incentives to understand curricular developments and acquire teaching skills.

Objective: To evaluate the feasibility and effectiveness of shared learning of clinical skills for medical and nursing students at the University of Manchester., Design: Medical and nursing students learned clinical skills in either uniprofessional or multiprofessional groups. These groups rotated through skills stations taught by multiprofessional facilitators. The groups stayed together for a series of 3 sessions held at weekly intervals (an induction meeting followed by 2 3-hour teaching sessions). Both quantitative and qualitative methods were used to evaluate the project., Context: A total of 113 Year 3 students registered on the Medical (n = 41), Bachelor of Nursing (Honours) (n = 43) or the Diploma for Professional Studies in Nursing (n = 29) courses participated in the project which was set in the clinical skills unit of a teaching hospital., Results: Pre- and post self-evaluation of confidence levels for the taught skills revealed a statistically significant increase for all skills. The primary reason students gave for participation in the project was to learn or consolidate skills. An additional inducement for participation was the opportunity to share knowledge and observations between professional groups. Tutors also evaluated the experience favourably, particularly with regard to small group discussions. They indicated that the programme provided an opportunity to standardise clinical skills teaching., Conclusion: Collaborative learning opportunities for nursing and medical students are feasible and add value to the learning experience. Data indicate positive outcomes of learning in multiprofessional groups, comprising increased confidence levels, increased understanding of others' professional roles and personal development.

Objective: To explore the acquisition of knowledge in anaesthetic practice using qualitative methods., Methods: An ethnographic study examining the nature of expertise in anaesthesia in one English hospital. The study used qualitative research methods, including observation of anaesthetic practice and interviews with members of the anaesthetic team. An integral part of the study was a process of feedback to the anaesthetic team including presenting observational data and conducting debriefing interviews with individual team members., Results: The study highlights the continued importance of the clinical apprenticeship in passing on knowledge, but also emphasizes the central role of practising independently in the acquisition of skills. Anaesthetists who participated in debriefing interviews or read observational transcripts found the experience valuable for thinking about their own practice., Discussion: One suggestion arising from the use of qualitative methods in this setting is that the type of detailed, systematic observation and data recording used in this study could be beneficial in the training and, possibly, appraisal of anaesthetists. This novel and innovative application of qualitative methods in anaesthesia is described and discussed with a view to broadening the debate about specialist training.

Introduction: As we move from standard 'long case' final examinations to new objective structured formats, we need to ensure the new is at least as good as the old. Furthermore, knowledge of which examination format best predicts medical student progression and clinical skills development would be of value., Methods: A group of medical students sat both the standard long case examination and the new objective structured clinical examination (OSCE) to introduce this latter examination to our Medical School for final MB. At the end of their pre-registration year, the group and their supervising consultants submitted performance evaluation questionnaires., Results: Thirty medical students sat both examinations and 20 returned evaluation questionnaires. Of the 72 consultants approached, 60 (83%) returned completed questionnaires. No correlation existed between self- and consultant reported performance. The traditional finals examination was inversely associated with consultant assessment. Better performing students were not rated as better doctors. The OSCE (and its components) was more consistent and showed positive associations with consultant ratings across the board., Discussion: Major discrepancies exist between the 2 examination formats, in data interpretation and practical skills, which are explicitly tested in OSCEs but less so in traditional finals. Standardised marking schemes may reduce examiner variability and discretion and weaken correlations across the 2 examinations. This pilot provides empirical evidence that OSCEs assess different clinical domains than do traditional finals. Additionally, OSCEs improve prediction of clinical performance as assessed by independent consultants., Conclusion: Traditional finals and OSCEs correlate poorly with one another. Objective structured clinical examinations appear to correlate well with consultant assessment at the end of the pre-registration house officer year.

Objectives: To promote safe prescribing and administration of medicines in the pre-registration house officer (PRHO) year through a programme of structured teaching and assessment for final year medical students., Design: Forty final year medical students from two medical schools were randomly allocated either to participate in a pharmacist facilitated teaching session or to receive no additional teaching. Teaching comprised five practical exercises covering seven skills through which students rotated in small groups. One month later, a random sample of 16 taught and 16 non-taught students participated in a nine-station objective structured clinical examination (OSCE) to assess the impact of the teaching., Setting: Manchester School of Medicine (MSM), and Kings College School of Medicine and Dentistry (KCSMD)., Participants: Final year medical student volunteers., Main Outcome Measures: The need for teaching as indicated by student prior experience; questionnaire rating of student acceptability of teaching and assessment; self-rating of student confidence post-assessment, and student performance assessed by OSCE., Results: The study demonstrated that the taught group achieved higher scores in eight OSCE stations. Four of these were statistically significant (P < or= 0.005). Taught students felt more confident performing the skills on five stations. From 0 to 47.5% students had prior experience of the skills taught. The post-teaching questionnaire evaluated exercises positively on several criteria, including provision of new information and relevance to future work., Conclusions: Structured teaching provided an effective and acceptable method of teaching the medicines management skills needed in the PRHO year. The structured approach complemented variable precourse clinical experience.

Objectives: To evaluate a national continuing professional development (CPD) scheme through the views and experiences of its participants., Methods: A qualitative focus group methodology was used. Forty-nine career grade paediatricians were allocated to nine focus groups according to their work settings, ages and posts. All groups discussed the following: (a) ease or difficulty of achieving CPD requirements; (b) whether a personal professional development plan (PDP) enabled the planning process for CPD; (c) whether CPD participation facilitated changes in practice, and (d) their views on the CPD system in operation at the time of the study., Results: Taking part in CPD had a positive effect on participants' clinical practice and broadened their professional and academic base. The main difficulties in achieving CPD were variable financial support (especially for non-consultant staff) and pressure due to extra work accumulating during study leave. The quality of internal CPD meetings was inconsistent. A professional development plan was useful for planning CPD needs, but there was a conflict between the educational and training needs of the individual and the employing NHS Trusts. The scheme's guidelines were clear but there were reservations about its layout and the system of recording points., Conclusion: This study enabled discovery of the views of paediatricians participating in a national CPD scheme operated by the Royal College of Paediatrics and Child Health. Consequently, changes were made to the scheme's presentation (but not content) and process of recording points. Barriers to achieving CPD requirements were identified and are being monitored. Efforts to involve non-consultant career grade paediatricians have been increased.

Background: There is still a great deal to be learnt about teaching and assessing undergraduate communication skills, particularly as formal teaching in this area expands. One approach is to use the summative assessments of these skills in formative ways. Discourse analysis of data collected from final year examinations sheds light on the grounds for assessing students as 'good' or 'poor' communicators. This approach can feed into the teaching/learning of communication skills in the undergraduate curriculum., Setting: A final year UK medical school objective structured clinical examination (OSCE)., Methods: Four scenarios, designed to assess communication skills in challenging contexts, were included in the OSCE. Video recordings of all interactions at these stations were screened. A sample covering a range of good, average and poor performances were transcribed and analysed. Discourse analysis methods were used to identify 'key components of communicative style'., Findings: Analysis revealed important differences in communicative styles between candidates who scored highly and those who did poorly. These related to: empathetic versus 'retractive' styles of communicating; the importance of thematically staging a consultation, and the impact of values and assumptions on the outcome of a consultation., Conclusion: Detailed discourse analysis sheds light on patterns of communicative style and provides an analytic language for students to raise awareness of their own communication. This challenges standard approaches to teaching communication and shows the value of using summative assessments in formative ways.

Context: The NHS Plan has indicated the need to increase the number of doctors in the NHS. To accommodate the substantial increase in student numbers in Birmingham, clinical teaching will need to expand from its traditional base within established teaching hospitals (THs) to district general hospitals (DGHs). Previous studies elsewhere have suggested the experience of students who undertake clinical attachments in DGHs is different from that of students attached to THs. We sought to investigate whether such differences exist in the West Midlands region and to explore the opportunities and problems such differences may present to educators and students alike., Methods: A questionnaire-based survey of the TH and DGH experiences of all medical students in their final year (2000/01) of undergraduate training at the University of Birmingham Medical School was carried out., Results: A total of 80% of students responded. Respondents indicated that both the identification of learning objectives and the provision of teaching to meet such objectives were likely to occur in TH and DGH settings equally. However, other differences emerged, suggesting that DGHs offer a friendlier and more supportive learning environment, with greater opportunities for the acquisition of hands-on practical experience., Conclusions: At present, the popularity of DGHs derives from the attitudes of staff and the opportunities for hands-on experience. However, as student numbers increase, DGHs may be required to take on additional teaching commitments. Will DGHs be able to retain their existing educational characteristics or will they take on those associated with established THs?

Background: Good professional regulation depends on high quality procedures for assessing professional performance. Professional assessment can also have a powerful educational impact by providing transparent performance criteria and returning structured formative feedback., Aim: This paper sets out to define some of the fundamental principles of good assessment design., Conclusions: It is essential to clarify the purpose of the assessment in question because this drives every aspect of its design. The intended focus for the assessment should be defined as specifically as possible. The scope of situations over which the result is intended to generalize should be established. Blueprinting may help the test designer to select a representative sample of practice across all the relevant aspects of performance and may also be used to inform the selection of appropriate assessment methods. An appropriately designed pilot study enables the test designer to evaluate feasibility, acceptability, validity (with respect to the intended focus) and reliability (with respect to the intended scope of generalization).

Purpose: To examine the validity of a written knowledge test of skills for performance on an OSCE in postgraduate training for general practice., Methods: A randomly-selected sample of 47 trainees in general practice took a knowledge test of skills, a general knowledge test and an OSCE. The OSCE included technical stations and stations including complete patient encounters. Each station was checklist rated and global rated., Results: The knowledge test of skills was better correlated to the OSCE than the general knowledge test. Technical stations were better correlated to the knowledge test of skills than stations including complete patient encounters. For the technical stations the rating system had no influence on the correlation. For the stations including complete patient encounters the checklist rating correlated better to the knowledge test of skills than the global rating., Conclusion: The results of this study support the predictive validity of the knowledge test of skills. In postgraduate training for general practice a written knowledge test of skills can be used as an instrument to estimate the level of clinical skills, especially for group evaluation, such as in studies examining the efficacy of a training programme or as a screening instrument for deciding about courses to be offered. This estimation is more accurate when the content of the test matches the skills under study. However, written testing of skills cannot replace direct observation of performance of skills.

Introduction: Newly qualified doctors require an appropriate level of confidence for their new roles. Development of this confidence was a key objective in the final year of a new integrated course with an emphasis on student self-direction., Context: There are 5 placements in the final year course. Students use a Learning Planner to help them choose suitable placements and objectives to serve their learning needs. Educational supervision focuses on helping students determine their objectives and assessing them against these., Methods: Course evaluation was by means of a questionnaire during final assessments. Cohorts of 310 and 316 students in successive years completed the evaluation. The interrelationship between variables was explored using logistic regression., Results: 220/310 students in the 2000 cohort and 214/316 in the 2001 cohort agreed they felt confident with their prospective role as a pre-registration house officer (PRHO). Confidence was significantly associated with confidence in their clinical skills, belief in their ability to cope with uncertainty and feeling able to work as a team member. The experience of the 2 hospital placements and (in 2000 only) the elective was associated with increased confidence. In all placements helpful educational supervision and the achievement of the self-directed learning plan was associated with increased confidence as a potential doctor., Conclusion: Students perceive a relationship between learning experiences in the final year of a self-directed course and development of confidence for their future role. Whilst further elucidation of the nature of this relationship is required, this provides encouragement to curriculum planners to promote self-direction.

Background and Study Aims: The Royal College of General Practitioners has designed its Fellowship by Assessment (FBA) programme with the twin goals of promoting higher standards of care and offering GPs a professional challenge. By November 2000, 223 eligible doctors (2%) had opted to take FBA. This number is increasing annually. There is, however, little research to account for why GPs undertake it, or what the barriers might be. The aim of our study was to investigate GPs' experience and thinking on this issue., Methods: A total of 13 GPs who had attained Fellowship by Assessment in the Tamar and Severn Faculties were invited to participate in a qualitative study. They were identified from the list of RCGP Fellows in the Institute of General Practice, University of Exeter, and purposefully selected to include trainers and non-trainers, men and women, rural and urban practitioners, and single-handed and large practices. Analysis of in-depth interviews was informed by grounded theory., Findings: FBA served to acknowledge high standards of care. There was some variation in views about FBA, however, ranging from a perspective which prized the professional award, to the view that endorsed it as a pragmatic and useful way of structuring and monitoring improvements. Fellowship by Assessment improves the care of patients and empowers the doctors by improving their confidence. It is, however, hugely time-consuming and while our findings suggest it should be encouraged, there is a need for ways to be found whereby doctors may be supported in this form of professional development.

Introduction: Most medical schools in the UK have been engaged in major curriculum reform based on their premises of what might improve undergraduate medical education. In 1994 the course at the medical school of the University of Manchester changed to an integrated course using problem-based learning throughout and with increased emphasis on community-based medical education. This study explores whether the new curriculum has produced any differences in perceptions of how well graduates are prepared for the role of pre-registration house officer., Methods: A postal questionnaire was used to survey 1998 Manchester graduates (traditional course) and 1999 Manchester graduates (new course), three months into their first pre-registration house officer placement. A similar questionnaire was sent to the educational supervisors who were supervising the graduates. The questionnaire was designed to measure perceptions of levels of preparedness for the role of pre-registration house officer, using a list of broad areas of competence and specific skills listed in the General Medical Council's 'The New Doctor'., Results: Graduates rated the new course significantly more effective for 12 of the 19 broad competences and eight of the 13 specific skills that were listed. The 'new' graduates rated their understanding of disease processes lower than the 'traditional' graduates, but there was no difference in the ratings given by the educational supervisors for this. Overall the educational supervisors rated the new course as better preparing graduates in five of the competences., Conclusions: Overall, the evaluation shows that a major change in curriculum approach has changed the profile of the perceived preparedness of graduates for entering professional practice.

Background: When training for junior doctors is being planned, little discussion is focused on what outcomes hospitals are trying to achieve with regard to education/training, i.e. on what makes the ideal hospital doctor. Instead, the primary focus is on the requirements of the syllabi of the Royal Colleges (credentialing) and the requirements of service delivery (job description). Current literature has no qualitative studies of any longitude in which middle-grade doctors are asked about their vision of the ideal hospital doctor, what they feel can be done to help realize this vision, and how they feel about their own training., Methods: This study examined data principally collected through a series of semistructured interviews conducted with eight specialist registrars (SpRs), four each from the North Trent and South Thames rotations over a period of 18 months. Additional information was taken from focus groups, interviews with programme directors, and questionnaires., Findings: A model was created of the SpRs' perceptions of the key attributes of an ideal hospital doctor and of how these may be achieved in training. Eight broad areas were identified: clinical knowledge and skills; key clinically related generic/non-clinical skills; self-directed learning and medical education; implementing change management; applying strategic and organizational skills in career planning; consultation skills; research; and key personal attributes., Conclusions: SpRs are articulate in expressing their own expectations of their training and have considerable insight into the components of good training. Further improvement could be made and will require significant commitment from both trainees and trainers.

Objective: The principal aim of undergraduate medical education is to produce competent pre-registration house officers (PRHOs). We examined and compared the perceptions of graduates and educational supervisors concerning how well prepared graduates were for their first post., Methods: A postal questionnaire was sent to house officers who had graduated from Manchester 3 months earlier and also to educational supervisors of PRHOs in the North-west Region. The questionnaires were based on the competencies set out by the General Medical Council of the United Kingdom., Results: The response rates were 66% from the graduates and 76% from the supervisors. Of the 18 broad areas of competence listed, only four were rated more than 'quite well prepared' by at least 50% of the graduates ('understanding disease processes', 'communicating effectively', 'awareness of limitations' and 'working in a team'). Similarly, more than half of educational supervisors rated graduates as more than quite competent in only three areas ('awareness of limitations', 'keeping accurate records' and 'working in a team'). Within the competencies surveyed, there were differences between the perceptions of graduates and educational supervisors on the preparedness of graduates for the skills they may require as a pre-registration house officer., Conclusion: Overall, given that most graduates and supervisors perceived the preparedness as 'quite well' or less, the undergraduate course had only partially met its objectives. A mismatch in ratings could be attributed to either inappropriate expectations on the part of the educational supervisors or the graduates or an inaccurate assessment by either group of respondents.

Objectives: To evaluate the effects of introducing specialised ward based teachers (WBTs) who had a broad remit to improve third year medical undergraduates' clinical experience., Design: Quantitative and qualitative methods including interviews with WBTs, participating consultants and SIFT co-ordinator; student questionnaire and evaluations; analysis of Objective Structured Clinical Examination (OSCE) scores to ascertain if exposure to WBTs affected OSCE scores., Setting: Two university teaching hospitals., Participants: Third year undergraduate medical students from one school of medicine; four WBTs; 25 consultants; SIFT co-ordinator., Main Outcome Measures: Student evaluations. Student questionnaires. Student OSCE scores. Interview data., Results: WBTs had a demonstrable effect on student performance in OSCE examinations. 94% of students either agreed or strongly agreed that WBTs had helped them develop their examination skills and 87% either agreed or strongly agreed that WBTs had helped them develop their history taking skills. Interview data indicated that the consultants and SIFT co-ordinator considered that WBTs made an important contribution to clinical teaching., Conclusions: This study suggests that specialised WBTs are one way to manage clinical experience and enhance learning of undergraduate medical students. As clinical teaching moves into earlier parts of the undergraduate curriculum and into the community there is potential for this role to be developed.

Background: Consultation skills are vitally important in general practice (GP), and now form part of the summative assessment of GP registrars in the UK. GP trainers need to be skilled in teaching consultation skills, and also need the time and resources to ensure that their registrars are competent in consultation skills., Aims: To describe the teaching methods used by GP trainers in one deanery, the frequency of teaching of consultation skills, the problems encountered and the training that GP trainers have themselves received both in consultation skills and how to teach them., Method: Postal questionnaire survey of all the 164 trainers in the Yorkshire Deanery., Results: Replies were received from 129 trainers (response rate 79%) of which 123 could be analysed. Of these trainers, 45 (37%) trainers taught consultation skills fewer than five times a year, 45 (37%) five to 10 times, and 14 (11%) more than 10 times a year. A total of 24 trainers reported problems with teaching consultation skills, most commonly lack of time, technical difficulties, and unreceptive registrars, and 97 (79%) trainers had had some postgraduate training in consultation skills with 112 (91%) reporting some form of teacher training., Conclusion: There is considerable variation in the reported frequency of teaching consultation skills, the models used, and the preparation of trainers for teaching, despite a systematic approach to teacher training in the Yorkshire Deanery.

Objectives: To ascertain the effect of 12 months spent as a GP registrar on perceived skills in palliative care., Design: A previously validated questionnaire for use with medical undergraduates is modified and used to survey perceived skills in five aspects of providing palliative care in five different scenarios at two points during the 12-month period of general practice vocational training where no specific teaching intervention is conducted., Setting: The West Midlands., Participants: 210 GP registrars., Results: Perceived skill ratings were seen to significantly increase during the 12-month period, but anxiety in caring for the dying did not significantly decrease. Ratings of skills were lowest when caring for a child dying with leukaemia or a young adult dying with AIDS. In addition, other important variables which had a statistically significant influence were gender and age, but interestingly not the number of previous senior house officer (SHO) posts undertaken or whether the respondent had had formal teaching on the subject in the past., Conclusion: It might therefore be postulated that training as a GP registrar has an important impact on the development of perceived skills in palliative care.

Objective: To assess the relationship between clinical experience, learning style and performance in an objective structured clinical examination (OSCE) in medical students at the end of their first clinical year., Design: Prospective study of undergraduate students taking an OSCE examination at the end of their first clinical year., Subjects: 194 undergraduate medical students (95 male)., Main Outcome Measures: Performance in the OSCE examination, the Entwhistle Learning Style Inventory1 and a composite self-reported score of clinical activity during the students first clinical year., Results: Performance in the OSCE examination was related to well-organized study methods but not to clinical experience. A significant relationship between clinical experience and organized deep-learning styles suggests that knowledge gained from clinical experience is related to learning style., Conclusions: The relationship between clinical experience and student performance is complex. Well-organized and strategic learning styles appear to influence the benefits of increased clinical exposure. Further work is required to elucidate the most beneficial aspects of clinical teaching.

Objectives: This study analysed the errors made by 16 final-year medical students in a classroom prescribing exercise. The aim was to gain greater understanding of the reasons for non-optimal prescribing and of how to improve basic training in pharmacotherapeutics., Methods: The task was to adjust a patient's phenytoin sodium dosage to achieve better control of seizures. It was based on a real-life case, and was presented as a written exercise. Process-tracing and think-aloud techniques were used to study the students' performance., Results: The results suggest that the root cause of the errors was lack of a knowledge base which integrated scientific knowledge with clinical know-how. Three different clinical reasoning strategies were observed. Students who followed an incremental strategy demonstrated superior scientific knowledge and this resulted in less hazardous errors. Those who followed gambling or backward-reasoning strategies appeared to possess inferior scientific knowledge and this resulted in more hazardous errors., Conclusions: The results support current trends towards integrating basic medical science into a foundation of clinical know-how, as in the problem-based curriculum. They also emphasize the importance of a thorough grounding in medical science as a means of minimizing error.

A survey was undertaken at the University of Sheffield Medical School to identify clinical and other professional skills which are required on graduation and to assess whether and when these skills have been acquired. The purpose of the survey was to identify core practical skills, defined as skills which the majority of clinical firms require and which, in addition, were used by the majority of Pre-registration house officers (PRHOs). The survey ws conducted by questionnaires which were circulated to the following four sample groups (number in sample: % response rate): (1) consultants in clinical firms taking undergraduates and post-graduates from Sheffield Medical School (63: 75%); (2) house officers starting their pre-registration year (118; 52%); (3) house officers ending their pre-registration year (120: 43%); and (4) undergraduates starting their final year (110: 65%). The questionnaire contained a stimulus list of 31 clinical and four personal skills with an opportunity for respondents to list other skills they felt to be important. Of the 35 skills listed on the questionnaire, 26 were identified as core practical skills. Fifteen of the core skills had been acquired by the majority of students by the time they graduated, 13 of which were acquired prior to the final undergraduate year. Core skills not acquired as an undergraduate were acquired as a PRHO. The survey acted as a quality control mechanism for teaching at both undergraduate and post graduate levels and provided the basis of a medical school core of practical skills on the basic medical education continuum.

Undergraduate medical education in the UK is changing due to both education pressure (from the General Medical Council) and changes in the hospital service. As a result the role of general practice in providing core clinical experience is under debate. The purpose of this study was to determine the clinical contact available for junior clinical medical clerks (third year) attached to five general practices. We report here on the clinical experience recorded by students during 106 sessions (74% of possible sessions). One hundred and one patients were seen, 54% females; ages ranging from 14 to 92. Four hundred and twenty-six symptoms were recorded; the largest category (36%) was CVS/respiratory followed by neurological (20%). Shortness of breath was the commonest single symptom (46% in the CVS/respiratory category). Three hundred and seventy-one signs were recorded; 48% were in the CVS/respiratory category, 33% in the neurological category. Cardiac murmurs were the commonest single sign (34% of the CVS/respiratory category). Sixty-nine separate comments were made by students about the range of clinical experience available; all were favourable. Forty-eight per cent of comments highlighted the availability of patients with appropriate symptoms and signs. This study has demonstrated that general practices can provide appropriate clinical exposure which complements hospital teaching for junior students.

There is an increasing trend in undergraduate education towards teaching clinical skills from a community base. A new clinical curriculum was introduced in Newcastle upon Tyne in 1995, beginning with an integrated clinical skills course. Although the attitudes and views of general practitioners (GPs) towards community-based clinical teaching have previously been reported, their perceived training needs have not been formally identified. The aims of this study were to identify the competencies needed by GPs for community-based clinical skills teaching, to compare and contrast these needs with their hospital colleagues, and to use the results to develop a teaching programme for the clinical tutors involved in the new course. In order of priority, the GPs and hospital tutors expressed similar needs: small-group teaching skills, assessing student needs, giving effective feedback and assessment of student performance, with a preference for the teaching to be organized within local teaching units. Most GPs and hospital tutors (73 and 69%, respectively) requested a distance-learning pack to complement the teaching. General practitioners rated resources for improving their individual clinical skills more highly than their hospital colleagues: for example, videotapes demonstrating examination techniques. Forty-six per cent of GP tutors had received some formal training in teaching methods compared to 29% of hospital tutors. The implications of the results for developing a 'Teaching the Teachers' course for clinical tutors are discussed.

The 5-week module in general practice for final-year students at the University of Sheffield is based on practice attachments and student-directed learning in small groups. This paper describes how the summative assessment process of the module was revised to incorporate the notion of competence-based assessment, and how general practitioner tutors, departmental tutors and students were involved in this revision. The question 'What are students expected to know and be able to do by the end of the module?' was answered in terms of a statement of the key purpose of the module and a list of intended learning outcomes. The question 'How can we find out if students have achieved these outcomes?' was addressed by developing check-lists of criteria for observed behaviours and for the written products of students' actions.

During 1991-1992 a confidential questionnaire was administered to a sample of United Kingdom medical students to determine if undergraduate education improved students' perceived competence at eight practical procedures. Of 2521 students given questionnaires, 1483 (58.8%) replied; 948 (65.5%) had had some obstetric and 866 (60.8%) some neonatal education. Such education did improve students' perceived competence (P < 0.001) on self-assessed Likert scales, but most still believe themselves not to be competent when they have completed their obstetric and neonatal education. Regression models were able to explain much (38.7-65.1%) of the variability in perceived competence at obstetric procedures: obstetric education, performing practical procedures, and witnessing deliveries in a general practitioner unit were all associated with higher competence; but less (4.8-20.8%) of the variability in perceived neonatal competence. It is suggested that undergraduate experience should be congruent with the aims and objectives of obstetric and neonatal education, and that these need to be reviewed in the light of the recent General Medical Council proposed changes to medical education.

In the revised medical curriculum at Sheffield University, a new 4-week introductory clinical course has been introduced to teach communication skills, clinical history-taking and physical examination. There is no formal examination for the course, which has been evaluated by feedback from students and tutors with questionnaires and group discussion.

A teaching package is described for teaching interview skills to large blocks of medical students whilst on their psychiatric attachment. The aims of this package are to reduce students' concerns about interviewing psychiatric patients, to reinforce students' knowledge of basic interviewing skills and to introduce students to the particular skills required in taking a psychiatric history and mental state examination. The package emphasizes the following teaching methods: 'hands-on' experience of interviewing a patient in front of small groups of peers; peer feedback using check-lists which focus on three major aspects of interviewing; elicitation of facts, elicitation of feelings and control of the interview; facilitation of small-group discussions in the presence of senior psychiatrist. The active involvement of all students in interviewing psychiatric patients engages them in the learning process. Peer involvement increases motivation and was deemed by students as a supportive and constructive exercise. The presence of a senior psychiatrist ensures that discussion is focused on the process of interviewing rather than on patient pathology. Ideally this package would precede focused training throughout the subsequent psychiatric placement.

Videotapes were developed for testing the ability to detect psychiatric phenomena, methods of questioning and interview technique. These were capable of discriminating between the performance of home graduates (HGs) and foreign graduates (FGs) and were consistent with other test results. These were significant differences between HGs and FGs on all tests before and after teaching. HGs started with high scores on all tests and these remained high, although no significant improvement occurred with teaching. FGs started with lower scores and showed improvement on the videotape test only, after teaching. HGs and FGs were exposed to video teaching methods but FGs rated video demonstration as a more helpful teaching mode.

The previous paper (Rix et al., 1985) described the production of two videotaped clinical examinations for use in assessing undergraduate medical students during their psychiatry clerkship. In this paper assessments by videotape are compared with conventional assessments available to the examiners. The highest correlations were between the videotape examination results and written multiple choice questionnaire results, suggesting that they test a common area of clinical competence: knowledge and interpretation of psychopathology. Videotape examination results correlated poorly or not at all with the teachers' global ratings and clinical examination results, which may be indicative of relative success in devising procedures for the assessment of fairly independent abilities.

In this paper the production is described of two videotaped clinical examinations for use in assessing the ability of medical students to observe, name and interpret psychopathology. The method of preparing the videotape is described in detail and data are presented concerning the ability of each item to respond to knowledge and skills acquired during the clerkship, as well as the item-whole correlations for each text item. Examination of the changes in scores over the course of the clerkship and item-whole correlations led to a reappraisal of teaching in certain topic areas.