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It is important to establish the predictive validity of medical school grades. The strength of predictive validity and the ability to identify at-risk students in medical schools depends upon assessment systems such as number grades, pass/fail (P/F) or honours/pass/fail (H/P/F) systems. This study was designed to examine the predictive validity of number grades in medical school, and to determine whether any important information is lost in a shift from number to P/F and H/P/F grading systems. The participants in this prospective, longitudinal study were 6656 medical students who studied at Jefferson Medical College over 3 decades. They were grouped into 10 deciles based on their number grades in Year 1 of medical school. Participants were compared on academic accomplishments in Years 2 and 3 of medical school, medical school class rank, delayed graduation and attrition, performance on medical licensing examinations and clinical competence ratings in the first postgraduate year. Results supported the short- and longterm predictive validity of the number grades. Ratings of clinical competence beyond medical school were predicted by number grades in medical school. We demonstrated that small differences in number grades are statistically meaningful, and that important information for identifying students in need of remedial education is lost when students who narrowly meet faculty's expectations are included with the rest of the class in a broad ‘pass’ category. The findings refute the argument that knowledge of sciences basic to medicine is not critical to subsequent performance in medical school and beyond if an appropriate evaluation system is used. Furthermore, the results of this study raise questions about abandoning number grades in favour of a pass/fail system. Consideration of these findings in policy decisions regarding assessment systems of medical students is recommended. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Background No attempt has been made to give a systematic overview of the innovative use of unannounced or incognito standardised patients. Objective To provide a systematic overview of all published studies with incognito standardised patients assessing doctors in actual practice situations using sound reliable and valid standardised patient methodology. Methods Systematic literature search in Medline, Eric and Psyclit with piloted search terms, followed by retrieving additional papers from reference lists. All papers were scored with a predefined protocol-sheet using predefined inclusion and exclusion criteria. Results Forty papers referring to 21 projects with incognito standardised patients were found and described in detail. The majority of studies were conducted in primary care and were descriptive. Discussion There is a need for research on the additional value of the incognito standardised patient methodology and for a consensus on how to report on accuracy and consistency of standardised patients. [ABSTRACT FROM AUTHOR]

Objective To develop generic criteria for the global assessment of clinical procedural competence and to quantify the extent to which existing checklists allow for holistic assessment of procedural competencies. Methods We carried out a systematic review and qualitative analysis of published clinical procedural skills assessment checklists and enumerated the contents of each. Source materials included all English-language papers published from 1990 to June 2005, identified from 18 databases, which described or referred to an assessment document for any clinical procedural skill. A pair of reviewers identified key generic themes and sub-themes through in-depth analysis of a subset of 20 checklists with iterative agreement and independent retesting of a coding framework. The resulting framework was independently applied to all checklists by pairs of reviewers checking for the emergence of new themes and sub-themes. Main outcome measures were identification of generic clinical procedural skills and the frequency of occurrence of each in the identified checklists. Results We identified 7 themes (‘Procedural competence’, represented in 85 [97%] checklists; ‘Preparation’, 65 [74%]; ‘Safety’, 45 [51%]; ‘Communication and working with the patient’, 32 [36%]; ‘Infection control’, 28 [32%]; ‘Post-procedural care’, 24 [27%]; ‘Team working’, 13 [15%]) and 37 sub-themes, which encapsulated all identified checklists. Of the sub-themes, 2 were identified after the initial coding framework had been finalised. Conclusions It is possible to develop generic criteria for the global assessment of clinical procedural skills. A third and a half of checklists, respectively, do not enable explicit assessment of the key competencies ‘Infection control’ and ‘Safety’. Their assessment may be inconsistent in assessments which use such checklists. [ABSTRACT FROM AUTHOR]

Purpose The development of self-regulated learning is a major focus of our problem-based learning (PBL) medical programme. Students who are unsuccessful in assessments often seem to lack insight into the standard of their own performance, yet the ability to self-assess accurately is essential for the effective self-management of learning. The aim of this project was to evaluate the accuracy of self- and peer-assessment according to academic performance. Method In 2004, 175 3rd-year students undertook an integrated, case-based, short-essay, formative assessment. After the assessment they were provided with model answers and marking criteria. Students marked their own assessment paper and the paper of one of their peers. Assessment papers were subsequently marked by faculty members. The following data was available for each student: self-mark, faculty-mark, score awarded by a peer and the score that they awarded to their peer. Self-assessment and peer-assessment ability was compared to overall academic performance. Results Low-achieving students score themselves and their peers generously. High-achieving students score themselves more harshly than faculty. However, they score their peers accurately. Conclusion In the 3rd year of the programme low-achieving students are unable to assess accurately the quality of their own work or the work of their peers in a formative written assessment. The PBL curriculum does not guarantee the appropriate development of self-assessment skills. [ABSTRACT FROM AUTHOR]

Educators across the world are charged with the responsibility of producing core learning outcomes for medical curricula. However, much educational theory exists which deliberates the value of learning outcomes in education. This paper aims to discuss the problems surrounding outcomes-based curricula in medical education, using insights from educational theory. The paper begins with a discussion of the traditions, values and ideologies of medical curricula. It continues by analysing the issue of control within the curriculum and argues that curriculum designers and teachers control product-orientated curricula, leading to student disempowerment. The paper debates outcomes-based curricula from an ideological perspective and argues that learning outcomes cannot specify exactly what is to be achieved as a result of learning. The paper argues that medical schools should adopt a model for co-operative control of the curriculum, thus empowering learners. The paper also suggests that medical educators should determine the value of precise learning outcomes before blindly adopting an outcomes-based model. [ABSTRACT FROM AUTHOR]

Context The white paper ‘Trust, Assurance and Safety: the Regulation of Health Professionals in the 21st Century’ proposes a single, generic multi-source feedback (MSF) instrument in the UK. Multi-source feedback was proposed as part of the assessment programme for Year 1 specialty training in histopathology. Methods An existing instrument was modified following blueprinting against the histopathology curriculum to establish content validity. Trainees were also assessed using an objective structured practical examination (OSPE). Factor analysis and correlation between trainees’ OSPE performance and the MSF were used to explore validity. All 92 trainees participated and the assessor response rate was 93%. Reliability was acceptable with eight assessors (95% confidence interval 0.38). Factor analysis revealed two factors: ‘generic’ and ‘histopathology’. Pearson correlation of MSF scores with OSPE performances was 0.48 ( P = 0.001) and the histopathology factor correlated more highly (histopathology r = 0.54, generic r = 0.42; t = − 2.76, d.f. = 89, P < 0.01). Trainees scored least highly in relation to ability to use histopathology to solve clinical problems (mean = 4.39) and provision of good reports (mean = 4.39). Three of six doctors whose means were < 4.0 received free text comments about report writing. There were 83 forms with aggregate scores of < 4. Of these, 19.2% included comments about report writing. Results Specialty-specific MSF is feasible and achieves satisfactory reliability. The higher correlation of the ‘histopathology’ factor with the OSPE supports validity. This paper highlights the importance of validating an MSF instrument within the specialty-specific context as, in addition to assuring content validity, the PATH–SPRAT (Histopathology–Sheffield Peer Review Assessment Tool) also demonstrates the potential to inform training as part of a quality improvement model. [ABSTRACT FROM AUTHOR]

Context This paper sets out to analyse and interpret the complex events of the last 20 years in order to understand how the teaching and learning of clinical communication has emerged as a core part of the modern undergraduate medical curriculum in most medical schools in the UK. Methods The paper analyses the effects of key political, sociological, historical and policy influences on clinical communication development. Results Political influences include: the effects of neo-liberalism on society and on the professions in general; the challenging of traditional notions of professionalism in medicine; the creation of an internal market within the National Health Service, and the disempowerment of the medical lobby. Sociological influences include: the effects of a ‘marketised’ society on medicine and subtle shifts in the doctor−patient relationship because of this; the emergence of globalised information through the Internet, and the influence of increased litigation against doctors. Historical influences include: the effects of a change in emphasis for medical education away from an inflated factual curriculum towards a curriculum that recognises the importance of student attitudes and the teaching and learning of clinical communication skills. Policy influences include the important effects of Tomorrow's Doctors and the Dearing Report on the modern medical curriculum. Conclusions The paper concludes with a developmental map that charts the complex influences on clinical communication teaching and learning and a brief commentary on the growing body of teachers who deliver and develop the subject today. [ABSTRACT FROM AUTHOR]

Context The move towards competence-based medical education has created a need for instruments that support and assess competence development. Portfolios seem suitable but mixed reports of their success are emerging. Methods To examine the effectiveness of portfolios, we searched PubMed and EMBASE using the keyword ‘portfol*’, PsychInfo and ERIC using the keywords ‘portfol*’ and ‘medical education’ and references of retrieved papers for empirical studies on portfolios in all phases of medical education. Thirty of 1939 retrieved papers met the inclusion criteria and were analysed. Data were collated against the research question, number of subjects, design, setting, findings and limitations, purpose and content, mentoring and assessment. We analysed impact using a modified version of Kirkpatrick’s hierarchy. Results Because differences across studies precluded statistical meta-analysis, the data were analysed by context, goals and procedure. Positive effects were strongest in undergraduate education. Important factors for success were: clearly communicated goals and procedures; integration with curriculum and assessment; flexible structure; support through mentoring, and measures to heighten feasibility and reduce required time. Moderately good inter-rater reliability was reported and global criteria and discussions among raters were beneficial. Formative and summative assessment could be combined. Without assessment, portfolios were vulnerable to competition from other summative assessment instruments. Conclusions For portfolios to be effective in supporting and assessing competence development, robust integration into the curriculum and tutor support are essential. Further studies should focus on the effectiveness and user-friendliness of portfolios, the merits of holistic assessment procedures, and the competences of an effective portfolio mentor. [ABSTRACT FROM AUTHOR]

Objective To develop and assess the feasibility and psychometric properties of multi-source feedback questionnaires to monitor international medical graduates practising in Canada under ‘defined’ licences. Method Four questionnaires (patient, co-worker, colleague and self) were developed and administered in 2 phases through paper-based and telephone or Internet formats. Reliability was assessed with Cronbach's alpha and generalisability coefficient analyses. Validity was established through mean ratings, ‘unable to respond’ rates and factor analyses. Results A total of 37 doctors participated in the 2 phases. Overall response rates were 70% for patients, 86% for co-workers, 72% for medical colleagues and 92% for self, with response rates higher for the paper-based format than the Internet and phone formats. The instruments had high internal consistency reliability, with Cronbach's alphas of 0.83 for self-assessment and > 0.90 for the other instruments. The generalisability coefficients were Ep2 = 0.71 for 25 patients on a 13-item survey, Ep2 = 0.59 for 8 co-workers on a 13-item survey, and Ep2 = 0.67 for 8 colleagues on a 21-item questionnaire. The range of mean scores was narrow (between 4 and 5) for all items and all surveys. The factor analyses identified that 2 factors accounted for 70% or more of the variance for the patient and colleague surveys and 60% of the variance for the co-worker survey. Conclusion These data suggest that the instruments have reasonable psychometric properties. Traditional survey methods (i.e. paper-based) yielded better results than Internet or phone methods for this group of doctors. [ABSTRACT FROM AUTHOR]

Objective This paper explores the thesis that medical education is the cultural transmission to learners of specific values, which are increasingly expressed as graduation competencies. As testing is a powerful way to transmit cultural values to learners in a brief period of time, competency-based assessments can be an instrument of cultural compression in medical education. Methods The author reviewed medical literature to illustrate the concepts from educational anthropology, led the process one medical school used to develop its list of graduation competencies, and conducted a citation search about competency domains. Results There is support in the literature for viewing medical education as an example of cultural transmission and compression and for the assertion that testing influences student behaviour. The graduation competency statements developed by the school reflect traditional and emergent values. The citation search data confirmed that some competency domains reflected traditional values, while others reflected more emergent values. Conclusion Concepts from educational anthropology are relevant to medical education and provide perspectives for understanding contemporary issues such as competency-based assessments. [ABSTRACT FROM AUTHOR]

Introduction This paper describes the development and implementation of an educational intervention to help general practitioners (GPs) recognise young people with first episode psychosis. Method The Medical Research Council complex interventions framework was used to guide the development of the intervention. The theoretical phase included a literature review of previous educational interventions in primary care and consideration of the literature on attitude formation and change, and the relationship between attitudes and behaviour. The modelling phase included focus groups with GPs and service users, and a training needs analysis questionnaire administered to GPs. The 2-stage intervention consisted of a video featuring role-plays of primary care consultations, GP-led discussion and discussion with early intervention service users. The acceptability and utility of the educational programme was evaluated using a 5-point Likert scale questionnaire administered at the end of each session. Results General practitioners from each of the 39 intervention practices participated in the initial session and from 27 practices in the booster session. Information about symptoms and signs of first episode psychosis was the most valued aspect of the initial session. The booster session was also well received, with GPs valuing the opportunity to gain insight into first episode psychosis from users. Conclusions This paper adds a pragmatic description to the literature on the development of educational interventions in primary care. The Medical Research Council framework helped to identify and clarify component parts of the intervention and how the active components may relate to the expected outcome of behaviour change. [ABSTRACT FROM AUTHOR]

INTRODUCTION This paper extends the work of an earlier publication by the same author which reported the findings of a case study designed to investigate how medical students learn and are taught in the operating theatre. The earlier paper was descriptive in nature, examining the challenges students face as learners in theatres. These were conceptualised around 3 key domains: the challenge posed by the physical environment; the challenge of the educational task, and the challenge of managing and negotiating a role as a participant in the professional workplace of theatres. This paper focuses exclusively on the third domain. It presents an interpretive model of teaching and learning in the operating theatre, drawing largely on conceptual frameworks developed within the literature on learning in work-based settings. METHODS A multimethod strategy included observation in theatres, interviews with students and surgeons, and a student survey. The themes that characterised the case were identified and the relationships among these themes were explored, leading to the development of the model. Symbolic interactionism provided the underlying theoretical framework. CONCLUSION In any particular theatre session, the way in which learning evolves or is obstructed for any student, and the shape that teaching takes, depends on the interpretations that the student and the surgeon make in `sizing up' the teaching and learning environment. How surgeons and students interpret and respond to each others' behaviour, style, attitude and even demeanour, has consequences for the way teaching and learning develop. The concepts of legitimacy and trust underpin these interpretations and are central to understanding the processes of teaching and learning in this setting. [ABSTRACT FROM AUTHOR]

Context Peer physical examination (PPE) has been employed for several decades as part of the formal curriculum for learning clinical skills. Most of the existing studies exploring students’ attitudes towards PPE are single-site and use quantitative methods. Currently, there is a lack of theoretical underpinning to PPE as a learning method. Methods Using an adaptation of the Examining Fellow Students questionnaire, we captured qualitative data from Year 1 medical students about their views and concerns around learning using PPE. The study was set in six schools across five countries (the UK, Australia, New Zealand, Japan and Hong Kong). Students provided free text comments that were later transcribed and analysed using framework analysis. Results A total of 617 students provided comments for analysis. This paper focuses on several related themes about the complexities of students’ relationships within the context of PPE and their reflections on peer examination in comparison with genuine patient examination. Students drew parallels and differences between the peer examiner–examinee relationship and the doctor–patient relationship. They explained how these two types of relationship differed in nature and in terms of their levels of interaction. Discussion Our findings illuminate the interactional and complex nature of PPE, drawing out concerns and ambiguities around relationships, community and rules. We discuss our results in light of Engeström’s model of activity theory (AT) and provide recommendations for educational practice and further research based on the principles of AT. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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). [ABSTRACT FROM AUTHOR]

Context Considerable research has been conducted recently into the notion of patient-centred consulting. The primary goal of this approach is to establish a clear understanding of the patient's perspective on his or her problem, and to allow this understanding to inform both the explanation and planning stages of the consultation. The quality of this understanding is largely determined by the empathic accuracy achieved by the doctor; the primary benefit is a therapeutic rapport between doctor and patient. Methods To highlight the role of empathy and communication skills in establishing rapport, we initially developed a model which seeks to draw the various motivational and skill elements identified in separate research papers into a comprehensive model of the journey towards shared understanding between doctor and patient. We then conducted an initial validation of the model via qualitative analysis involving general practitioners (GPs) and clinical psychologists. Results The validation offered encouraging support for the principal elements of the model. Specific suggestions for clarification and extension were then incorporated in a revised model. Conclusions The model appears to capture the dynamic process of establishing a therapeutic relationship (rapport) between doctor and patient, defined by the quality of the doctor's understanding of the patient's perspective on his or her problem. Arguably, the most important contribution of the model is to highlight the fact that ‘empathy’ and consequent ‘rapport’ are not mystical or exclusive concepts but, rather, involve the use of specific skills accessible at some level by all. [ABSTRACT FROM AUTHOR]

Background Problem-based learning (PBL) as an approach to the instruction of medical students has attracted much attention in recent years. However, its effect on the performance of its graduates is the subject of considerable debate. This article presents data from a large-scale study among graduates of a problem-based medical school and those of a conventional medical school to contribute to this discussion. Purpose To study the longterm effects of problem-based medical training on the professional competencies of graduates. Methods A questionnaire was sent to all graduates since 1980 of a problem-based and a conventional medical school. Participants were requested to rate themselves on 18 professional competencies derived from the literature. Results The graduates of the PBL school scored higher on 14 of 18 professional competencies. Graduates of the problem-based school rated themselves as having much better interpersonal skills, better competencies in problem solving, self-directed learning and information gathering, and somewhat better task-supporting skills, such as the ability to work and plan efficiently. There were no sizeable differences with regard to general academic competencies, such as conducting research or writing a paper. Graduates from the conventional school rated themselves as having slightly more medical knowledge. The findings were shown to be valid and robust against possible response bias. Conclusion The findings suggest that PBL not only affects the typical PBL-related competencies in the interpersonal and cognitive domains, but also the more general work-related skills that are deemed important for success in professional practice. [ABSTRACT FROM AUTHOR]

Introduction Career choice, sense of professional identity and career behaviour are influenced, subject to change and capable of development through interaction with the learning environment. In this paper workplace learning discourses are used to frame ongoing concerns associated with higher specialist training. Data from the first stage of a multimethods investigation into recruitment into and retention in specialties in the West Midlands is used to consider some possible effects of the specialist learning environment on recruitment and retention. Methods The aim of the study was to identify issues, through interviews with 6 consultants and questionnaires completed by specialist registrars from specialties representing a range of recruitment levels. These would inform subsequent study of attributes and dispositions relevant to specialist practice and recruitment. The data were analysed using NVivo© software for qualitative data management. Results Participants' perceptions are presented as bipolar dimensions, associated with: curriculum structure, learning relationships, assessment of learning, and learning climate. They demonstrate ongoing struggle between different models of workplace learning. Conclusion Changes in the postgraduate education of doctors seem set to continue well into the future. How these are reflected in the balance between workplace learning models, and how they influence doctors' sense of identity as specialists suggests a useful basis for examination of career satisfaction and recruitment to specialties. [ABSTRACT FROM AUTHOR]

Background To establish international standards for medical schools, an appropriate panel of experts must decide on performance standards. A pilot test of such standards was set in the context of a multidimensional (multiple-choice question examination, objective structured clinical examination, faculty observation) examination at 8 leading schools in China. Methods A group of 16 medical education leaders from a broad array of countries met over a 3-day period. These individuals considered competency domains, examination items, and the percentage of students who could fall below a cut-off score if the school was still to be considered as meeting competencies. This 2-step process started with a discussion of the borderline school and the relative difficulty of a borderline school in achieving acceptable standards in a given competency domain. Committee members then estimated the percentage of students falling below the standard that is tolerable at a borderline school and were allowed to revise their ratings after viewing pilot data. Results Tolerable failure rates ranged from 10% to 26% across competency domains and examination types. As with other standard-setting exercises, standard deviations from initial to final estimates of the tolerable failure rates fell, but the cut-off scores did not change significantly. Final, but not initial cut-off scores were correlated with student failure rates ( r = 0.59, P = 0.03). Discussion This paper describes a method to set school-level outcome standards at an international level based on prior established standard-setting methods. Further refinement of this process and validation using other examinations in other countries will be needed to achieve accurate international standards. [ABSTRACT FROM AUTHOR]

Aim This paper in the series on professional assessment provides a practical guide to writing key features problems (KFPs). Key features problems test clinical decision-making skills in written or computer-based formats. They are based on the concept of critical steps or ‘key features’ in decision making and represent an advance on the older, less reliable patient management problem (PMP) formats. Method The practical steps in writing these problems are discussed and illustrated by examples. Steps include assembling problem-writing groups, selecting a suitable clinical scenario or problem and defining its key features, writing the questions, selecting question response formats, preparing scoring keys, reviewing item quality and item banking. Conclusion The KFP format provides educators with a flexible approach to testing clinical decision-making skills with demonstrated validity and reliability when constructed according to the guidelines provided. [ABSTRACT FROM AUTHOR]

This discussion paper argues for a creative synthesis between simulation and clinical practice, where an iterative process of continual interaction ensures that skills are learned and reinforced within the context of everyday professional life.Evidence is mounting that long-established approaches to surgical training are no longer acceptable in the current ethical and professional climate. This paper considers alternatives to the traditional approach of‘learning by doing’ in a clinical context, focusing on recent developments in the technology of simulation and virtual reality. Clinical expertise is a complex phenomenon and no single theory can account for its acquisition. After a brief contextualising overview, Vygotsky's‘zone of proximal development’ is proposed as a conceptual framework for task-based surgical learning that takes place within skills laboratories. The discussion is located within a wider context of educational theory, drawing on current thinking about situated learning and apprenticeship. The notion of‘legitimate peripheral participation’ in a complex professional environment places technical skill alongside a range of other competencies that are necessary to safe practice.Simulation offers a safe environment within which learners can repeatedly practise a range of clinical skills without endangering patients. Comprehensive simulated environments allow a move away from isolated tasks to more complex clinical situations, recreating many of the challenges of real life. Such simulations, however, can operate in isolation from their clinical context, ignoring the learning needs of individuals within a real health care environment. To realise its full potential as a learning aid, simulation must be usedalongsideclinical practice and linked closely with it. [ABSTRACT FROM AUTHOR]

Practice inevitably narrows over time. Therefore, testing of established doctors requires that their assessment be tailored to a far narrower practice than is appropriate for testing of new doctors who have not yet differentiated. In this paper, we address the conceptual challenges of tailoring physician assessment to individual practice. Testing of established doctors needs to reflect that physicians specialise, often in idiosyncratic ways; otherwise, the testing will not be credible among established doctors and will not reflect the realities of their practice. Despite the importance of these goals, the conceptual and methodological challenges of creating tailored assessments remain daunting. [ABSTRACT FROM AUTHOR]

Objective This paper aims to describe current views of the relationship between competence and performance and to delineate some of the implications of the distinctions between the two areas for the purpose of assessing doctors in practice. Methods During a 2-day closed session, the authors, using their wide experiences in this domain, defined the problem and the context, discussed the content and set up a new model. This was developed further by e-mail correspondence over a 6-month period. Results Competency-based assessments were defined as measures of what doctors do in testing situations, while performance-based assessments were defined as measures of what doctors do in practice. The distinction between competency-based and performance-based methods leads to a three-stage model for assessing doctors in practice. The first component of the model proposed is a screening test that would identify doctors at risk. Practitioners who ‘pass’ the screen would move on to a continuous quality improvement process aimed at raising the general level of performance. Practitioners deemed to be at risk would undergo a more detailed assessment process focused on rigorous testing, with poor performers targeted for remediation or removal from practice. Conclusion We propose a new model, designated the Cambridge Model, which extends and refines Miller's pyramid. It inverts his pyramid, focuses exclusively on the top two tiers, and identifies performance as a product of competence, the influences of the individual (e.g. health, relationships), and the influences of the system (e.g. facilities, practice time). The model provides a basis for understanding and designing assessments of practice performance. [ABSTRACT FROM AUTHOR]

Summary The utility of any assessment tool critically depends on its level of acceptance by those on whom the assessment impacts. Performance assessment impacts on three distinct groups: patients/consumers, doctors and employers. While these groups may have conflicting beliefs and expectations of performance assessment, the process must be made acceptable to all. This can happen through an exploration of the beliefs and wishes of the key stakeholders in relation to performance assessment, together with the potential rewards and costs. This paper draws on the psychology literature in describing an effective model for change management. It outlines some strategies for each of the three key elements of any successful strategy for change, i.e. getting started, facilitating the transition and ensuring consolidation. Such a practical approach will foster the acceptance of performance assessment structures among all stakeholders. [ABSTRACT FROM AUTHOR]

Summary The assessment of the performance of doctors in practice is becoming more widely accepted. While there are many potential purposes for such assessments, sometimes the consequences of the assessments will be ‘high stakes’. In these circumstances, any of the many elements of the assessment programme may potentially be challenged. These assessment programmes therefore need to be robust, fair and defensible, taken from the perspectives of consumer, assessee and assessor. In order to inform the design of defensible programmes for assessing practice performance, a group of education researchers at the 10th Cambridge Conference adopted a project management approach to designing practice performance assessment programmes. This paper describes issues to consider in the articulation of the purposes and outcomes of the assessment, planning the programme, the administrative processes involved, including communication and preparation of assessees. Examples of key questions to be answered are provided, but further work is needed to test validity. [ABSTRACT FROM AUTHOR]

Objectives The need to address cultural and ethnic diversity issues in medical education as a means to improve the quality of care for all has been widely emphasised. Cultural competence has been suggested as an instrument with which to deal with diversity issues. However, the implementation of culturally competent curricula appears to be difficult. We believe the development of curricula would profit from a framework that provides a practical translation of abstract educational objectives and that is related to competencies underlying the medical curriculum in general. This paper proposes such a framework. Methods The framework illustrates the following cultural competencies: knowledge of epidemiology and the differential effects of treatment in various ethnic groups; awareness of how culture shapes individual behaviour and thinking; awareness of the social context in which specific ethnic groups live; awareness of one’s own prejudices and tendency to stereotype; ability to transfer information in a way the patient can understand and to use external help (e.g. interpreters) when needed, and ability to adapt to new situations flexibly and creatively. Discussion The framework indicates important aspects in taking care of an ethnically diverse patient population. It shows that there are more dimensions to delivering high-quality care than merely the cultural. Most cultural competencies emphasise a specific aspect of a generic competency that is of extra importance when dealing with patients from different ethnic groups. We hope our framework contributes to the further development of cultural competency in medical curricula. [ABSTRACT FROM AUTHOR]

Objectives The ability to innovate new solutions in response to daily workplace challenges is an important component of adaptive expertise. Exploring how to optimally develop this skill is therefore of paramount importance to education researchers. This is certainly no less true in health care, where optimal patient care is contingent on the continuous efforts of doctors and other health care workers to provide the best care to their patients through the development and incorporation of new knowledge. Medical education programmes must therefore foster the skills and attitudes necessary to engage future doctors in the systematic development of innovative problem solving. The aim of this paper is to describe the perceptions and experiences of medical students in their third and fourth years of training, and to explore their understanding of their development as adaptive experts. Methods A sample of 25 medical students participated in individual 45–60-minute semi-structured interviews. Interviews were audiotaped, transcribed and entered into NVivo qualitative data analysis software to facilitate a thematic analysis. The analysis was both inductive, in that themes were generated from the data, and deductive, in that our data were meaningful when interpreted in the context of theories of adaptive expertise. Results Participants expressed a general belief that, as learners in the health care system, exerting any effort to be innovative was beyond the scope of their responsibilities. Generally, students suggested that innovative practice was the prerogative of experts and an outcome of expert development centred on the acquisition of knowledge and experience. Conclusions Students’ perceptions of themselves as having no responsibility to be innovative in their learning process have implications for their learning trajectories as adaptive experts. [ABSTRACT FROM AUTHOR]

Objective Modern postgraduate medical training requires both accurate and reliable selection procedures. An essential first step is to conduct detailed job analysis studies. This paper reports data on a series of job analyses to develop a competency model for three secondary care specialties (anaesthesia, obstetrics and gynaecology, and paediatrics). Methods Three independent job analysis studies were conducted. The content validity of the resulting competency domains was tested using a questionnaire-based study with specialty trainees (specialist registrars [SpRs]) and consultants drawn from the three specialties. Job analysis was carried out in the Yorkshire and the Humber region in the UK. The validation study was administered with additional participants from the West Midlands and Trent regions in the UK. This was an exploratory study. The outcome is a set of competency domains with data on their importance at senior house officer, SpR and consultant grade in each specialty. Results The study produced a model comprising 14 general competency domains that were common to all the three specialties. However, there were significant between-specialty differences in both definitions of domains and the ratings of importance attached to them. Conclusions The results indicate that a wide range of attributes beyond clinical knowledge and academic achievement need to be considered in order to ensure doctors train and work within a specialty for which they have a particular aptitude. This has significant implications for developing selection criteria for specialty training. Future research should explore the content validity of these competency domains in other secondary care specialties. [ABSTRACT FROM AUTHOR]

Context Reflective practice has been suggested to be an important instrument in improving clinical judgement and developing medical expertise. Empirical evidence supporting this suggestion, however, is absent. This paper reports on an experiment conducted to study the effects of reflective practice on diagnostic accuracy. Methods Participants were 42 internal medicine residents in hospitals in 2 states in the northeast of Brazil. They diagnosed 16 clinical cases. The experiment employed a repeated measures design, with 2 independent variables: the complexity of clinical cases (simple or complex), and the reasoning approach induced to diagnose the case (participants were instructed to diagnose each case either through pattern recognition or reflective reasoning). The dependent variable was the accuracy of the diagnosis provided for each case. All participants participated in each of the 2 levels of both independent variables. Results A main effect of case complexity emerged. There was no statistically significant main effect of reflective practice. However, a significant interaction effect was found between case complexity and mode of processing (F[1,41] = 4.48, P < 0.05), indicating that although reflective practice did not make a difference to accuracy of diagnosis in simple cases, it had a positive effect when diagnosing complex cases. Conclusions Reflective practice had a positive effect on diagnosis of complex, unusual cases. Non-analytical reasoning was shown to be as effective as reflective reasoning for diagnosing routine clinical cases. Findings support the idea that reflective practice may particularly improve diagnoses in situations of uncertainty and uniqueness, reducing diagnostic errors. [ABSTRACT FROM AUTHOR]

Context Three decades ago Elstein et al. published their classic book on medical expertise, in which they described their failure to identify superior performance by peer-nominated diagnosticians using high- and low-fidelity simulations of the everyday practice of doctors. Objective This paper reviews the results of subsequent research, with a particular emphasis on the progress toward Elstein et al.’s goal of capturing the essence of superior clinical performance in standardised settings in order to improve clinical practice. Results Research following publication of Elstein et al.’s book was influenced by laboratory research in cognitive psychology, which resulted in a redirection of its original focus on capturing clinical performance in practice to studies of changes in cognitive processes as functions of extended clinical experience. There is currently renewed interest in linking laboratory research with studies of the acquisition of superior (expert) performance in the clinic. Conclusions Research on medical expertise and simulation training in technical procedures and diagnosis provide exciting opportunities for establishing translational research on the acquisition of superior (expert) performance in the clinic by capturing it with representative tasks in the laboratory, reproducing it for experimental analysis, and developing training activities, such as deliberate practice, that can induce measurable improvements in performance in the clinic. [ABSTRACT FROM AUTHOR]

Objectives The aim of this review was to evaluate the effectiveness of medical skills laboratories or simulators. In particular, it aimed to determine if performance in medical skills laboratories is transferable to actual clinical performance and maintained over time. Methods A range of databases was utilised to search for relevant papers published from 1998 to June 2006. Articles were included in the review if they met a number of criteria that included the evaluation of a skills laboratory or simulator for the purpose of procedural skills training, that participants were either undergraduate medical students or postgraduate medical trainees, and that the study used a randomised, controlled trial (RCT) research design in evaluation. Results A total of 44 RCTs were identified for inclusion in the review. Overall, 32 (70%) studies reported that simulator training significantly improved procedural skills performance in comparison with standard or no training. Twenty (45%) RCTs assessed the transfer of simulator performance to clinical skills performance; however, 8 of these used animal models, not real patients. Only 2 studies assessed the maintenance of skills post-intervention, both at 4-month follow-up periods. Conclusions Medical skills laboratories do lead to improvement in procedural skills compared with standard or no training at all when assessed by simulator performance and immediately post-training. However, there is a lack of well designed trials addressing the crucial issues of transferability to clinical practice and retention of skills over time. Further research must be carried out to address these matters if medical skills laboratories are to remain an integral component of medical education. [ABSTRACT FROM AUTHOR]

Context The Bologna Declaration of 1999 has led to the initiation of profound changes within the European Higher Education Area. Methods This paper gives an overview of the Bologna Process, reviews the developments within European dental education that have arisen as a result of the Process, and describes the impact of the continuation of the Process on health science education in the UK. Conclusions The Bologna Process has led to the establishment of the European Higher Education Area, which is committed to implementing a series of action lines by 2010. Currently, we are just over halfway to 2010, and the importance of UK higher education institutions engaging with the Bologna Process is stressed. [ABSTRACT FROM AUTHOR]

Context The last 10 years have represented a period of significant reform within both the health care and education systems in France. In terms of its workforce, France faces a shortage of doctors, particularly in primary care. Methods This paper examines the French medical curriculum, student selection, licensure and continuing medical education and discusses the challenges currently facing French medical faculties. Results The French medical curriculum is defined nationally, with methods adapted at medical school level. There has been some uptake of innovative methods such as problem-based learning, skills-based teaching and performance-based assessment. However, traditional didactic teaching of scientific medicine and the apprenticeship model remain dominant. France uses a unique method of selection, which is the subject of much debate. Following a general year, medical students are subject to a selection examination that permits only a small number to continue studies. Similarly, at the end of medical school, a written test is used to rank students for the purpose of matching to specialty training. France has no national colleges or licensing authorities and thus authorisation to practise rests on the diploma delivered by each faculty of medicine. From 2005, continuing medical education became compulsory for all doctors. It includes the evaluation of medical practice. Conclusions French faculties of medicine face several challenges, including: rising numbers of students without a commensurate growth in the number of faculty members; an increasing emphasis on multidisciplinary health care; a drive towards mandatory continuing education and performance-based outcomes, and the development of national selection examinations that are knowledge-based. [ABSTRACT FROM AUTHOR]

Background The assessment of clinical procedural skills has traditionally focused on technical elements alone. However, in real practice, clinicians are expected to be able to integrate technical with communication and other professional skills. We describe an integrated procedural performance instrument (IPPI), where clinicians are assessed on 12 clinical procedures in a simulated clinical setting which combines simulated patients (SPs) with inanimate models or items of medical equipment. Candidates are observed remotely by assessors whose data are fed back to the clinician within 24 hours of the assessment. This paper describes the feasibility of IPPI. Results A full-scale IPPI and 2 pilot studies with trainee and qualified health care professionals has yielded an extensive data set including 585 scenario evaluations from candidates, 60 from clinical assessors and 31 from simulated patients (SPs). Interview and questionnaire data showed that for the majority of candidates IPPI provided a powerful and valuable learning experience. Realism was rated highly. Remote and real-time assessment worked effectively, although for some procedures limited camera resolution affected observation of fine details. Discussion IPPI offers an innovative approach to assessing clinical procedural skills. Although resource-intensive, it has the potential to provide insight into individual's performance over a spectrum of clinical scenarios and at no risk to the safety of patients. Additional benefits of IPPI include assessment in real time from experts (allowing remote rating by external examiners) as well as provision of feedback from simulated patients. [ABSTRACT FROM AUTHOR]

Background The role of basic science, which provides causal explanations for clinical phenomena in medical education, is poorly understood. Schmidt has postulated that expert clinicians maintain this knowledge in ‘encapsulated’ form, indexed by words or phrases describing the processes. In the present paper we show that students who learn causal explanations have a more coherent understanding of the relation between diseases and clinical features which, in turn, influences recognition of words or phrases describing ‘encapsulated knowledge’ and the ability to maintain performance under speeded conditions. Hypotheses In comparison to students who simply learn the features of 4 diagnostic categories, students who learn a causal explanation will: (a) recognise words describing encapsulated knowledge more accurately and (b) maintain or improve diagnostic performance under speeded conditions. Methods Two studies were conducted involving 4 ‘pseudo-endocrinology’ diseases and undergraduate psychology students. One group learned signs and symptoms alone; the second group also learned a causal explanation. In study 1, they were then given a recognition memory task. In study 2, they were asked to diagnose new cases either (i) as quickly as possible or (ii) taking their time. Results In study 1, while there was no difference in recognising old words (90% versus 91%), the causal group was better able to recognise encapsulated and novel consistent words (50% versus 41%) ( P = 0.02). In study 2 there was an interaction; causal students performed better under speeded conditions (71% versus 66%) but worse under thoroughness conditions (67% versus 73%), as predicted. Conclusions Causal understanding leads to more coherent understanding of clinical conditions, which in turn leads to expert-like behaviour. [ABSTRACT FROM AUTHOR]

Background Doctors' interpersonal and communication skills correlate with improved health care outcomes. International medical organisations require competency in communication skills. The Accreditation Council for Graduate Medical Education (ACGME) developed a toolbox for assessing this competency and 5 others, yet none initially for teaching these skills. Purpose and methods The original focus in the development of the ACGME competencies was evaluation. This paper represents a significant step toward defining methods for teaching communication skills competencies. A total of 16 medical education leaders from medical schools worldwide, participating in the 2003 Harvard Macy Institute Program for Physician Educators, worked together to: (1) further define the ACGME competency in interpersonal and communication skills; (2) delineate teaching strategies for each level of medical education; and (3) create a teaching toolbox to integrate communication skills competencies into medical curricula. Four subgroups defined subcompetencies, identified teaching strategies for undergraduate, graduate and postgraduate medical training and brought their work to the larger group. The expanded communication competencies and teaching strategies were determined by a consensus of the larger group, presented to 80 Harvard Macy Scholars and Faculty for further discussion, then finalised by consensus. Conclusion The teaching toolbox expands the ACGME core communication competencies, adds 20 subcompetencies and connects these competencies to teaching strategies at each level of medical training. It represents the collaboration and consensus of a diverse international group of medical education leaders in a variety of medical specialities and institutions, all involved in teaching communication skills. The toolbox is applicable globally across different settings and specialities, and is sensitive to different definitions of health care. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction Observation, including identification of key pieces of data, pattern recognition, and interpretation of significance and meaning, is a key element in medical decision making. Clinical observation is taught primarily through preceptor modelling during the all-important clinical years. No single method exists for communicating these skills, and medical educators have periodically experimented with using arts-based training to hone observational acuity. The purpose of this qualitative study was to better understand the similarities and differences between arts-based and clinical teaching approaches to convey observation and pattern recognition skills. Method A total of 38 Year 3 students participated in either small group training with clinical photographs and paper cases (group 1), or small group training using art plus dance (group 2), both consisting of 3 2-hour sessions over a 6-month period. Findings Students in both conditions found value in the training they received and, by both self- and instructor-report, appeared to hone observation skills and improve pattern recognition. The clinically based condition appeared to have been particularly successful in conveying pattern recognition concepts to students, probably because patterns presented in this condition had specific correspondence with actual clinical situations, whereas patterns in art could not be generalised so easily to patients. In the arts-based conditions, students also developed skills in emotional recognition, cultivation of empathy, identification of story and narrative, and awareness of multiple perspectives. Conclusion The interventions studied were naturally complementary and, taken together, can bring greater texture to the process of teaching clinical medicine by helping us see a more complete ‘picture’ of the patient. [ABSTRACT FROM AUTHOR]

Introduction In Flanders an important part of training to become a general practitioner (GP) is undertaken within a general practice. This requires a GP trainer to know how to facilitate learning processes. This paper reports a study focused on the research question: Does short but individualised training of GP trainers contribute to their teaching competence? Method A total of 47 GP trainers were randomly divided into 2 groups of a pretest/post-test control group design. After a multiple-station teaching assessment test (MSTAT), the experimental group received a short but individualised training to improve teaching competence while the control group were given no specific programme regarding teaching competence. One year later, all participants were invited to sit the post-test. Results In all, 61 GP trainers participated in the pretest and 51 in the post-test; 44 GP trainers participated in both tests. Despite the large attrition, the internal validity of the experiment was preserved. Beginners gained a median score of 2.04 (on a scale of 0−5) on the first MSTAT. In the post-test, the experimental group (median = 3.12) scored significantly better on the entire test (Mann–Whitney U = 166.5, P < 0.05) compared with the control group (median = 2.84). However, the GP trainers in the control group also appeared to have made progress. Conclusion General practitioners who start as GP trainers have insufficient teaching competence to guarantee good coaching of students. A personal programme leads to progress in teaching competence; however, it would seem that more time and support are necessary to allow GP trainers to gain full teaching competence. The fact that the control group made progress as well suggests that the test had an important learning effect. [ABSTRACT FROM AUTHOR]

Background Traditional assessment has improved significantly over the past 50 years. A number of new testing methods are now in place, the computer is improving both the fidelity and efficiency of examinations, and the psychometric principles on which assessment rests are more sophisticated than ever. Aim There is growing interest in quality improvement and there are increasing demands for public accountability. This has shifted the focus of testing from education to work. The purpose of this paper is to describe the assessment of work. Discussion In contrast to traditional assessment, there are no ‘methods’ for the evaluation of work because the content and difficulty of the examination are not controlled in any fashion. Instead it is a matter of identifying the basis for the judgements (outcomes, process, or volume), deciding how the data will be gathered (practice records, administrative databases, diaries/logs, or observation), and avoiding threats to validity and reliability (patient mix, patient complexity, attribution, and numbers of patients). Future directions Overall, the assessment of doctors' performance at work is in its infancy and much research and development is needed. Nonetheless, it is being used increasingly in programmes of continuous quality improvement and accountability. It is critical that refinements occur quickly to ensure that patients receive the highest quality of care and that doctors are treated fairly and provided with the information they need to guide their professional development. [ABSTRACT FROM AUTHOR]

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. 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. Video- and audio-recorded consultations were subjected to conversation analysis. Output from discussion groups with patient representatives and health professionals underwent qualitative analysis. 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. 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. [ABSTRACT FROM AUTHOR]

Examinations based on using standardised patients (SPs) commonly use checklist recordings to evaluate students' clinical performance. This paper examines whether and to what extent item and rater characteristics affect the reliability of history checklist recording in an SP-based assessment. Checklist items were reviewed for the presence or absence of 5 item characteristics and a 2-point versus 3-point scoring scale. Agreement between checklist recordings obtained from SPs and clinician-examiners (CEs) were compared by item characteristics, scoring scale and CEs' level of involvement in the assessment. Based on 3179 pairs of recordings, the overall percentage of agreement between SPs and CEs was 83% (kappa = 0.64). Agreement was significantly higher for items scored on a 2-point than on a 3-point scale, and when the CE was also the author and the trainer of the station. After controlling for other factors, item characteristics were only marginally associated with level of interrater agreement. This study suggests that attention should be paid to specific aspects of checklist development and checklist recording training when an SP or CE is used as recorder. [ABSTRACT FROM AUTHOR]

Narrative inquiry is a form of qualitative research that takes story as either its raw data or its product. Science and narrative can be seen as two kinds of knowing, reflected in the distinction between evidence-based medicine derived from population studies and narrative-based medicine focused upon the single case. A similar tension exists in the field of narrative inquiry between cognitive-orientated analytical methods and affective-orientated methods of synthesis.This paper aims to make sense of narrative inquiry in clinical education through definition of‘narrative’, articulation of a typology of narrative research approaches, and critical examination in particular of analytical methods, the dominant approach in the literature. The typology is illustrated by research examples, and the role of medical education in developing expertise in narrative inquiry is discussed. An argument is made that the tension between analysis of the structure of stories and empathic use of stories can be seen as productive, stimulating expertise encompassing both approaches.Analytical methods tend to lose the concrete story and its emotional impact to abstract categorisations, which may claim explanatory value but often remain descriptive. Stemming from discomfort with more integrative methods derived from the humanities, a science-orientated medical education may privilege analytical methods over approaches of synthesis. Medical education can redress this imbalance through attention to‘thinking with stories’ to gain empathy for a patient's experience of illness. Such an approach can complement understanding of story as discourse − how narratives may be used rhetorically to manage both social interactions and identity. [ABSTRACT FROM AUTHOR]

Research in clinical reasoning has been conducted for over 30 years. Throughout this time there have been a number of identifiable trends in methodology and theory.This paper identifies three broad research traditions, ordered chronologically, are: (a) attempts to understand reasoning as a general skill − the‘clinical reasoning' process; (b) research based on probes of memory − reasoning related to the amount of knowledge and memory; and (c) research related to different kinds of mental representations − semantic qualifiers, scripts, schemas and exemplars.Several broad themes emerge from this review. First, there is little evidence that reasoning can be characterised in terms of general process variables. Secondly, it is evident that expertise is associated, not with a single basic representation but with multiple coordinated representations in memory, from causal mechanisms to prior examples. Different representations may be utilised in different circumstances, but little is known about the characteristics of a particular situation that led to a change in strategy.It becomes evident that expertise lies in the availability of multiple representations of knowledge. Perhaps the most critical aspect of learning is not the acquisition of a particular strategy or skill, nor is it the availability of a particular kind of knowledge. Rather, the critical element may be deliberate practice with multiple examples which, on the hand, facilitates the availability of concepts and conceptual knowledge (i.e. transfer) and, on the other hand, adds to a storehouse of already solved problems. [ABSTRACT FROM AUTHOR]

In medical education, assessment of medical competence and performance, important changes have taken place in the last 5 decades. These changes have affected the basic concepts in all 3 domains. In education constructivism has provided a completely new view on how students learn best. In assessment the change from trait-orientated to competency- or role-orientated thinking has given rise to a whole range of new approaches. Certain methods of education, such as problem-based learning (PBL), and assessment, however, are often seen as almost synonymous with the underlying concepts, and one tends to forget that it is the concept that is important and that a particular method is but 1 way of using a concept. When doing this, one runs the risk of confusing means and ends, which may hamper or slow down new developments. A similar problem seems to occur often in research of medical education. Here too, methods – or, rather, methodologies – are confused with research questions. This may lead to an overemphasis on research that fits well known methodologies (e.g. the randomised controlled trial) and neglect of what are sometimes even more important research questions because they do not fit well known methodologies. In this paper we advocate a return to the underlying concepts and a careful reflection of their use in various situations. [ABSTRACT FROM AUTHOR]

This paper describes the context of interprofessional training on clinical education wards (CEWs) and reports students' perceptions of this type of interprofessional and professional training. A 2-week interprofessional clinical course was designed for medical students in their surgical eighth term, and nursing, occupational therapy and physiotherapy students, all in their sixth term. Clinical tutors were responsible for the patients and also supervised the students. The goals for the students included: to provide the patients with good medical care, nursing and rehabilitation; to develop their own professional roles; to enhance their level of understanding of the other professions; to stress the importance of good communication for teamwork and for patient care; to enhance understanding of the role of the patient, and to become more aware of ethical aspects of health care. A questionnaire developed by teachers from the 4 educational departments was used. A total of 962 students responded (78%). The CEWs provided the students with good clinical practice in terms of training in their own professions as well in learning more about the other professions. The importance of good communication for teamwork and for patient care was recognised. The quality of supervision and students' perception of their own professional roles were important factors regarding satisfaction with the CEW course. The CEW course seemed to provide the students with an opportunity to develop their own professional roles and their functions as team members. [ABSTRACT FROM AUTHOR]

At a time of significant changes in medical education world-wide, the international dimensions and global issues relating to the application of new learning technologies have been recognised. The aim of this paper is to describe the adoption and integration within the curriculum in one United Kingdom (UK) medical school of ‘Harvey’, the Cardiology Patient Simulator, and the UMedic multimedia computer-based cardiology curriculum – resources developed in a medical school in the USA. The integration of the resources into the curriculum is described by 3 teachers actively involved in the cardiology curriculum of the UK medical school and 3 teachers associated with the development of resources in the USA. The review considers the adoption of Harvey and UMedic in the UK in programmes in relation to: curricular issues, training needs, learning outcomes, curriculum content and sequences of content, educational strategies, teaching and learning methods, assessment, communication about the curriculum and management of the curriculum. Learning resources, in the form of simulators and computer-based learning modules, developed in one country can be successfully adopted and implemented in another. Facets that facilitated the adoption included close liaison between the developers of the resources in the USA and the implementers in the UK, and careful and systematic planning including in-depth integration of the simulation-based resources into the required curriculum rather than their relegation to a peripheral ad hoc position. The successful use of simulators such as Harvey requires the presence of a ‘champion’, a clinician educator and a supporting administrative staff who ensure the simulator's appropriate use. [ABSTRACT FROM AUTHOR]

Changes in medical training and culture have reduced the acceptability of the traditional apprenticeship style training in medicine and influenced the growth of clinical skills training. Simulation is an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks. The number and range of commercially available technologies used in simulation for education of health care professionals is growing exponentially. These range from simple part-task training models to highly sophisticated computer driven models. This paper will review the range of currently available simulators and the educational processes that underpin simulation training. The use of different levels of simulation in a continuum of training will be discussed. Although simulation is relatively new to medicine, simulators have been used extensively for training and assessment in many other domains, most notably the aviation industry. Some parallels and differences will be highlighted. [ABSTRACT FROM AUTHOR]

This paper outlines the considerations to be made when establishing a clinical skills learning facility. Establishing a clinical skills learning facility is a complex project with many possible options to be considered. A number of professional groups, undergraduate or postgraduate, may be users. Their collaboration can have benefits for funding, uses and promotion of interprofessional education. Best evidence and educational theory should underpin teaching and learning. The physical environment should be flexible to allow a range of clinical settings to be simulated and to facilitate a range of teaching and learning methods, supported by computing and audio-visual resources. Facilities should be available to encourage self-directed learning. The skills programme should be designed to support the intended learning outcomes and be integrated within the overall curriculum, including within the assessment strategy. Teaching staff may be configured in a number of ways and may be drawn from a variety of backgrounds. Appropriate staff development will be required to ensure consistency and quality of teaching with monitoring and evaluation to assure appropriate standards. Patients can also play a role, not only as passive teaching material, but also as teachers and assessors. Clinical, diagnostic and therapeutic equipment will be required, as will models and manikins. The latter will vary from simple part task trainers to highly sophisticated human patient simulators. Care must be taken when choosing equipment to ensure it matches specified requirements for teaching and learning. Detailed planning is required across a number of domains when setting up a clinical skills learning facility. [ABSTRACT FROM AUTHOR]