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Background and aims: The purpose of this study was to understand more completely the (tacit) curriculum design models of medical faculty. We report on two research questions: (1) Can medical faculty give an account of their curriculum design assumptions? and (2) What are their assumptions concerning curriculum design? Method: We conducted an explorative, qualitative case study. We interviewed educational decision makers at the three Danish medical schools and associate professors from different courses concerning curriculum design. We carried out four individual, in-depth interviews and four focus groups with 20 participants in all. Results and conclusions: Only one decision maker had an explicit curriculum design model. However, all participants had assumptions concerning curriculum design. We displayed their assumptions as five essentially different and increasingly complex models: the method-driven, pragmatically driven content-driven, outcome-driven and vision-driven curriculum design models. In the five models, the role of learning outcomes differs. The differences range from a belief that learning outcomes are essential, to a belief that learning outcomes are unimportant, to a belief that learning outcomes are incompatible with higher education. Finally, we found that teachers do not necessarily play a clear, central role in curriculum design. [ABSTRACT FROM AUTHOR]

Background Thalassemia major can be cured with allogeneic hematopoietic stem cell transplantation. Persistent mixed chimerism develops in around 10% of transplanted thalassemic patients, but the biological mechanisms underlying this phenomenon are poorly understood.Design and Methods The presence of interleukin-10-producing T cells in the peripheral blood of eight patients with persistent mixed chimerism and five with full donor chimerism was investigated. A detailed characterization was then performed, by T-cell cloning, of the effector and regulatory T-cell repertoire of one patient with persistent mixed chimerism, who developed stable split erythroid/lymphoid chimerism after a hematopoietic stem cell transplant from an HLA-matched unrelated donor.Results Higher levels of interleukin-10 were produced by peripheral blood mononuclear cells from patients with persistent mixed chimerism than by the same cells from patients with complete donor chimerism or normal donors. T-cell clones of both host and donor origin could be isolated from the peripheral blood of one, selected patient with persistent mixed chimerism. Together with effector T-cell clones reactive against host or donor alloantigens, regulatory T-cell clones with a cytokine secretion profile typical of type 1 regulatory cells were identified at high frequencies. Type 1 regulatory cell clones, of both donor and host origin, were able to inhibit the function of effector T cells of either donor or host origin in vitro.Conclusions Overall these results suggest that interleukin-10 and type 1 regulatory cells are associated with persistent mixed chimerism and may play an important role in sustaining long-term tolerance in vivo. These data provide new insights into the mechanisms of peripheral tolerance in chimeric patients and support the use of cellular therapy with regulatory T cells following hematopoietic stem cell transplantation.

Abstract Background Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation. Methods Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed. Results At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9). Conclusions Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.

Abstract Background Junior physicians are sometimes sent in ambulances with critically ill patients who require urgent transfer to another hospital. Unfamiliar surroundings and personnel, time pressure, and lack of experience may imply a risk of insufficient treatment during transportation as this can cause the physician to loose the expected overview of the situation. While health care professionals are expected to follow complex algorithms when resuscitating, stress can compromise both solo-performance and teamwork. Aim To examine whether inter-hospital resuscitation improved with a structured team briefing between physician and ambulance crew in preparation for transfer vs. review of resuscitation guidelines. The effect parameters were physician team leadership (requesting help, delegating tasks), time to resuscitation key elements (chest compressions, defibrillation, ventilations, medication, or a combination of these termed "the first meaningful action"), and hands-off ratio. Methods Participants: 46 physicians graduated within 5 years. Design: A simulation intervention study with a control group and two interventions (structured team briefing or review of guidelines). Scenario: Cardiac arrest during simulated inter-hospital transfer. Results Forty-six candidates participated: 16 (control), 13 (review), and 17 (team briefing). Reviewing guidelines delayed requesting help to 162 seconds, compared to 21 seconds in control and team briefing groups (p = 0.021). Help was not requested in 15% of cases; never requesting help was associated with an increased hands-off ratio, from 39% if the driver's assistance was requested to 54% if not (p < 0.01). No statistically significant differences were found between groups regarding time to first chest compression, defibrillation, ventilation, drug administration, or the combined "time to first meaningful action". Conclusion Neither review nor team briefing improved the time to resuscitation key elements. Review led to an eight-fold increase in the delay to requesting help. The association between never requesting help and an increased hands-off ratio underpins the importance of prioritising available resources. Other medical and non-medical domains have benefited from the use of guidelines reviews and structured team briefings. Reviewing guidelines may compromise the ability to focus on aspects such as team leading and delegating tasks and warrants the need for further studies focusing on how to avoid this cognitive impairment.

Background: The training required for accurate assessment of umbilical catheter placement by ultrasonography (US) is unknown., Objective: To describe the learning curve and provide an estimate of the accuracy of physicians' US examinations (US skills) and self-confidence when examining umbilical catheter tip placement., Methods: Twenty-one physicians with minimal experience in US completed a 1.5-hour eLearning module. Ten piglets with catheters inserted in the umbilical vessels were used as training objects. Following eLearning each physician performed up to twelve 10-min US examinations of the piglets. Expert examinations were reference standards. Sensitivity and specificity of physicians' skills in detecting catheter tip placement by US was used to describe the learning curve. Self-confidence was reported by Likert scale after each examination., Results: Physicians' detection of a correctly placed and misplaced umbilical artery catheter tip increased by an odds ratio of 1.6 (95% CI: 1.1, 2.3) and 3.6 (95% CI: 1.7, 7.8) per examination performed. A sensitivity of 0.97 (95% CI: 0.80, 0.99) and specificity of 0.95 (95% CI: 0.84, 0.99) was reached after 6 examinations. For the venous catheter, US skills in detecting a misplaced catheter tip increased with an odds ratio of 2.4 (95% CI: 1.2, 4.8) per US examination. Overall, performance and self-confidence plateaus were reached after 6 examinations., Conclusion: We found steep learning curves for targeted US examination of umbilical catheter placement. eLearning followed by 6 examinations was found to be adequate training to perform with a sufficiently high accuracy and self-confidence to allow for point-of-care use., (© 2019 S. Karger AG, Basel.)

Early identification and support of strugglers in medical education is generally recommended in the research literature, though very little evidence of the diagnostic qualities of early teacher judgments in medical education currently exists. The aim of this study was to examine the validity of early diagnosis of struggling in medical school based on informal teacher judgements of in-class behavior. The study design was a prospective cohort study and the outcomes/truth criteria were anatomy failure and medical school drop out. Six weeks into an anatomy course, student tutors attempted to identify medical students, who they reckoned would fail the anatomy course or drop out, based on their everyday experiences with students in a large group educational setting. In addition, they were asked to describe the indicators of struggling they observed. Sixteen student tutors evaluated 429 medical students for signs of struggling. By week six, the student tutors were able to detect approximately 1/4-1/3 of the students who eventually failed or dropped out, and for ¾ of the strugglers they identified, they were correct in their judgments. Informal student tutor's judgements showed incremental validity for both outcomes when controlling for grades obtained in preceeding exams. Lack of participation, lack of commitment, poor academic performance, poor social interactions and general signs of distress were the main indicators of struggling identified. Teachers' informal judgements of in-class behavior may be an untapped source of information in the early identification of struggling medical students with added value above and beyond formal testing.

Introduction: The distribution of practice affects the acquisition of skills. Distributed practice has shown to be more effective for skills acquisition than massed training. However, it remains unknown as to which is the most effective distributed practice schedule for learning bronchoscopy skills through simulation training. This study compares two distributed practice schedules: One-day distributed practice and weekly distributed practice., Method: Twenty physicians in training were randomly assigned to one-day distributed or weekly distributed bronchoscopy simulation practice. Performance was assessed with a pre-test, a post-test after each practice session, and a 4-week retention test using previously validated simulator measures. Data were analysed with repeated measures ANOVA., Results: No interaction was found between group and test (F(4,72) <1.68, p>0.16), except for the measure 'percent-segments-entered', and no main effect of group was found for any of the measures (F(1,72)< 0.87, p>0.36), which indicates that there was no difference between the learning curves of the one-day distributed practice schedule and the weekly distributed practice schedule., Discussion: We found no difference in effectiveness of bronchoscopy skills acquisition between the one-day distributed practice and the weekly distributed practice. This finding suggests that the choice of bronchoscopy training practice may be guided by what best suits the clinical practice.

Background: The advanced life support guidelines recommend 2min of cardiopulmonary resuscitation (CPR) and minimal hands-off time to ensure sufficient cardiac and cerebral perfusion. We have observed doctors who shorten the CPR intervals during resuscitation attempts. During simulation-based resuscitation training, the recommended 2-min CPR cycles are often deliberately decreased in order to increase the number of scenarios. The aim of this study was to test if keeping 2-min CPR cycles during resuscitation training ensures better adherence to time during resuscitation in a simulated setting., Methods: This study was designed as a randomised control trial. Fifty-four 4th-year medical students with no prior advanced resuscitation training participated in an extra-curricular one-day advanced life support course. Participants were either randomised to simulation-based training using real-time (120s) or shortened CPR cycles (30-45s instead of 120s) in the scenarios. Adherence to time was measured using the European Resuscitation Council's Cardiac Arrest Simulation Test (CASTest) in retention tests conducted one and 12 weeks after the course., Results: The real-time group adhered significantly better to the recommended 2-min CPR cycles (time-120s) (mean 13; standard derivation (SD) 8) than the shortened CPR cycle group (mean 45; SD 19) when tested (p<0.001.), Conclusion: This study indicates that time is an important part of fidelity. Variables critical for performance, like adherence to time in resuscitation, should therefore be kept realistic during training to optimise outcome., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Context: Medical simulation training requires effective and efficient training strategies. Dyad practice may be a training strategy worth pursuing because it has been proven effective and efficient in motor skills learning. In dyad practice two participants collaborate in learning a task they will eventually perform individually. In order to explore the effects of dyad practice in a medical simulation setting, this study examined the effectiveness and efficiency of dyad practice compared with individual practice in the learning of bronchoscopy through simulation-based training., Methods: A total of 36 students of medicine were randomly assigned to either individual practice or dyad practice. The training setting included video-based instruction, 10 bronchoscopy simulator cases and instructor feedback. Participants in the dyad practice group alternated between physical and observational practice and hence physically undertook only half of the training cases undertaken by participants who practised individually. Pre-, post- and delayed (3 weeks) retention tests were used to assess skills according to previously validated simulator measures. Data were analysed using repeated-measures analysis of variance (anova) on each dependent measure., Results: A significant main effect of test was found for all measures (F2,67  > 23.32, p < 0.001), indicating improvement in performance from pre-tests to post-tests and retention tests. No interaction was found between test and group (F2,67  < 0.26, p > 0.49), indicating parallel learning curves. Most importantly, no main effect of group was found for any of the measures, indicating no difference between learning curves (F1,34  = 2.08, p < 0.16)., Conclusions: Individual practice and dyad practice did not differ in their effectiveness for the acquisition of bronchoscopy skills through supervised simulation training. However, dyad practice proved more efficient than individual practice because two participants practising in dyads learned as much as one participant practising individually but required the same instructor resources and training time as the single learner., (© 2014 John Wiley & Sons Ltd.)

Outcome based or competency based education (OBE) is so firmly established in undergraduate medical education that it might not seem necessary to ask why it was included in recommendations for the future, like the Flexner centenary report. Uncritical acceptance may not, however, deliver its greatest benefits. Our aim was to explore the underpinnings of OBE: its historical origins, theoretical basis, and empirical evidence of its effects in order to answer the question: How can predetermined learning outcomes influence undergraduate medical education? This literature review had three components: A review of historical landmarks in the evolution of OBE; a review of conceptual frameworks and theories; and a systematic review of empirical publications from 1999 to 2010 that reported data concerning the effects of learning outcomes on undergraduate medical education. OBE had its origins in behaviourist theories of learning. It is tightly linked to the assessment and regulation of proficiency, but less clearly linked to teaching and learning activities. Over time, there have been cycles of advocacy for, then criticism of, OBE. A recurring critique concerns the place of complex personal and professional attributes as "competencies". OBE has been adopted by consensus in the face of weak empirical evidence. OBE, which has been advocated for over 50 years, can contribute usefully to defining requisite knowledge and skills, and blueprinting assessments. Its applicability to more complex aspects of clinical performance is not clear. OBE, we conclude, provides a valuable approach to some, but not all, important aspects of undergraduate medical education.

Context: Learning complex procedural skills, such as bronchoscopy, through simulation training, imposes a high cognitive load on novices. Example-based learning has been shown to be an effective way to reduce cognitive load and enhance learning outcomes. Prior research has shown that modelling examples, in which a human model demonstrates the skill to a learner, were effective for learning basic surgical skills. However, principles derived from simple skills training do not necessarily generalise to more complex skills. Therefore, the present study examined the effectiveness of integrating modelling examples into simulation training for a more complex procedural skill - bronchoscopy. Moreover, this study extended previous simulation studies by using a physical demonstration rather than video-based modelling examples., Methods: Forty-eight medical students were randomised into a modelling group and a control group. They all practised on eight bronchoscopy simulation cases individually, followed by standardised feedback from an instructor. Additionally, the modelling group watched three modelling examples of the simulated bronchoscopy, performed by the instructor. These modelling examples were interspersed between cases. Assessments were carried out at pre-, post- and 3-week retention tests with simulator-measured performance metrics. The primary outcome measure was the percentage of segments entered/minute. Other measures were wall collisions, red-out, the percentage of segments entered and the time to completion. Group differences were examined using repeated measures analysis of variance (anova)., Results: A clear learning curve was observed for both groups, but as hypothesised, the modelling group outperformed the control group on all parameters except the percentage of segments entered on the post-test and retained this superiority at the retention test. For the primary outcome measure, the percentage of segments entered/minute, the modelling group achieved a 46% higher score at the post-test and a 43% higher score at the retention test., Conclusions: The present study shows, that integrating modelling examples into the curriculum of bronchoscopy simulation training optimises the role of the instructor and enhances novices' learning outcomes, presumably by optimising cognitive load during training., (© 2013 John Wiley & Sons Ltd.)

Background: Competence in transthoracic echocardiography (TTE) is unrelated to traditional measures of TTE competence, such as duration of training and number of examinations performed. This study aims to explore aspects of validity of an instrument for structured assessment of echocardiographic technical skills., Methods: The study included 45 physicians with three different clinical levels of echocardiography competence who all scanned the same healthy male following national guidelines. An expert in echocardiography (OG) evaluated all the recorded, de-identified TTE images blindly using the developed instrument for assessment of TTE technical skills. The instrument consisted of both a global rating scale and a procedure specific checklist. Two scores were calculated for each examination: A global rating score and a total checklist score. OG rated ten examinations twice for intra-rater reliability, and another expert rated the same ten examinations for inter-rater reliability. A small pilot study was then performed with focus on content validity. This pilot study included nine physicians who scanned three patients with different pathologies as well as different technical difficulties., Results: Validity of the TTE technical skills assessment instrument was supported by a significant correlation found between level of expertise and both the global score (Spearman 0.76, p<0.0001) and the checklist score (Spearman 0.74, p<0.001). Both scores were able to distinguish between the three levels of competence that were represented in the physician group. Reliability was supported by acceptable inter- and intra-rater values. The pilot study showed a tendency to improved scores with increasing expertise levels, suggesting that the instrument could also be used when pathologies were present., Conclusions: We designed and developed a structured assessment instrument of echocardiographic technical skills that showed evidence of validity in terms of high correlations between test scores on a normal person and the level of physician competence, as well as acceptable inter- and intra-rater reliability scores. Further studies should, however, be performed to determine the adequate number of assessments needed to ensure high content validity and reliability in a clinical setting.

Introduction: The first year following graduation from medical school is challenging as learning from books changes to workplace-based learning. Analysis and reflection on experience may ease this transition. We used Significant Event Analysis (SEA) as a tool to explore what pre-registration house officers (PRHOs) consider successful and problematic events, and to identify what problem-solving strategies they employ., Material and Methods: A senior house officer systematically led the PRHO through the SEA of one successful and one problematic event following a night call. The PRHO wrote answers to questions about diagnosis, what happened, how he or she contributed and what knowledge-gaining activities the PRHO would prioritise before the next call., Results: By using an inductive, thematic data analysis, we identified five problem-solving strategies: non-analytical reasoning, analytical reasoning, communication with patients, communication with colleagues and professional behaviour. On average, 1.5 strategies were used in the successful events and 1.2 strategies in the problematic events. Most PRHOs were unable to suggest activities other than reading textbooks., Conclusion: SEA was valuable for the identification of PRHOs' problem-solving strategies in a natural setting. PRHOs should be assisted in increasing their repertoire of strategies, and they should also be helped to "learn to learn" as they were largely unable to point to new learning strategies., Funding: not relevant., Trial Registration: not relevant.

The surgical educational environment is potentially stressful and this can negatively affect students' learning. The aim of this study was to investigate whether veterinary students' level of anxiety is higher in a surgical course than in a non-surgical course and if pre-surgical training in a Surgical Skills Lab (SSL) has an anxiety reducing effect. Investigations were carried out as a comparative study and a parallel group study. Potential participants were fourth-year veterinary students who attended a surgical course (Basic Surgical Skills) and a non-surgical course (Clinical Examination Skills); both courses were offered in multiple classes (with a total of 171 students in 2009 and 156 students in 2010). All classes in 2009 participated in the SSL stage of the Basic Surgical Skills course before performing live-animal surgery, and one class (28 students) in 2010 did not. Two validated anxiety questionnaires (Spielberger's state-trait anxiety inventory and Cox and Kenardy's performance anxiety questionnaire) were used. Anxiety levels were measured before the non-surgical course (111 students from 2009) and before live-animal surgery during the surgical course (153 students from 2009 and 28 students from 2010). Our results show that anxiety levels in veterinary students are significantly higher in a surgical course than in a non-surgical course (p<.001), and that practicing in a SSL helps reduce anxiety before live-animal surgery (p<.005).

A surgical educational environment is potentially stressful and can negatively affect students' learning. The aim of the present study was to investigate the emotions experienced by veterinary students in relation to their first encounter with live-animal surgery and to identify possible sources of positive and negative emotions, respectively. During a Basic Surgical Skills course, 155 veterinary fourth-year students completed a survey. Of these, 26 students additionally participated in individual semi-structured interviews. The results of the study show that students often experienced a combination of emotions; 63% of students experienced negative emotions, while 58% experienced positive ones. In addition, 61% of students reported feeling excited or tense. Students' statements reveal that anxiety is perceived as counterproductive to learning, while excitement seems to enhance students' focus and engagement. Our study identified the most common sources of positive and negative emotions to be "being able to prepare well" and "lack of self-confidence," respectively. Our findings suggest that there are factors that we can influence in the surgical learning environment to minimize negative emotions and enhance positive emotions and engagement, thereby improving students' learning.

Two major views on the relationship between basic science knowledge and clinical knowledge stand out; the Two-world view seeing basic science and clinical science as two separate knowledge bases and the encapsulated knowledge view stating that basic science knowledge plays an overt role being encapsulated in the clinical knowledge. However, resent research has implied that a more complex relationship between the two knowledge bases exists. In this study, we explore the relationship between immediate relevant basic science (physiology) and clinical knowledge within a specific domain of medicine (echocardiography). Twenty eight medical students in their 3rd year and 45 physicians (15 interns, 15 cardiology residents and 15 cardiology consultants) took a multiple-choice test of physiology knowledge. The physicians also viewed images of a transthoracic echocardiography (TTE) examination and completed a checklist of possible pathologies found. A total score for each participant was calculated for the physiology test, and for all physicians also for the TTE checklist. Consultants scored significantly higher on the physiology test than did medical students and interns. A significant correlation between physiology test scores and TTE checklist scores was found for the cardiology residents only. Basic science knowledge of immediate relevance for daily clinical work expands with increased work experience within a specific domain. Consultants showed no relationship between physiology knowledge and TTE interpretation indicating that experts do not use basic science knowledge in routine daily practice, but knowledge of immediate relevance remains ready for use.

Introduction: The dropout level from the Danish medical schools is high, but we have only little insight into this problem. The purpose of this study was to qualify the ongoing discussions concerning dropout., Material and Methods: In this retrospective cohort study, relevant variables were extracted from the established database of Aarhus University for the 639 students initiating medicine studies between 1 January 1999 and 31 December 2000. A multivariate pre-admission and post-admission model was examined., Results: Of the 639 medical students, 20% dropped out. Most students dropped out during their first year. The type of admission exam was a strong predictor of dropout in the pre-admission model, whereas previous higher education protected against dropout. Obtaining leave was a very strong predictor of dropout in the post-admission model, whereas high grades protected against dropout., Conclusion: The dropout rate has been decreasing during the past decade. Young people considering studying medicine could be advised to choose natural science subjects in high school, and a number of research questions concerning preparedness for medical school are worth pursuing. Leave or very low grades during the first and second study years might serve as red flags to supervisors., Funding: Study research was funded by Aarhus University., Trial Registration: Not relevant, register-based research with no biological human material cannot be notified to the Danish Committee System. The Danish Data Protection Agency allows schools to conduct anonymized, non-sensitive, educational analyses without notification.

Background: Visual expertise relies on perceptive as well as cognitive processes. At present, knowledge of these processes when diagnosing clinical cases mainly stems from studies with still pictures. In contrast, patient video cases constitute a dynamic diagnostic challenge that may simulate seeing and diagnosing a patient in person., Aims: This study investigates visual attention and the concomitant cognitive processes of clinicians diagnosing authentic paediatric video cases., Methods: A total of 43 clinicians with varying levels of expertise took part in this cross-sectional study. They diagnosed four brief video recordings of children: two with seizures and two with disorders imitating seizures. We used eye tracking to investigate time looking at relevant areas in the video cases and a concurrent think-aloud procedure to explore the associated clinical reasoning processes., Results: More experienced clinicians were more accurate in visual diagnosis and spent more of their time looking at relevant areas. At the same time, they explored data less, yet they built and evaluated more diagnostic hypotheses., Conclusions: Clinicians of varying expertise analyse patient video cases differently. Clinical teachers should take these differences into account when optimising educational formats with patient video cases., (Copyright © 2011 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.)

The purpose of this study was to compare which learning outcomes relating to an Interprofessional Training Unit (ITU) experience were found to be most important by students and by alumni. A cohort of 428 students in the ITU was asked to write three short statements describing the most important learning outcomes from the ITU. Alumni from the same cohort were after graduation asked the same question. Furthermore, they were asked to fill out a 12-item questionnaire. The statements concerning learning outcome were analysed qualitatively and categorized. The number of statements in each category was counted and tested for statistical difference between students and alumni. Students stated "uniprofessionalism" as the most important learning outcome followed by "interprofessionalism", "professional identity" and "learning environment". Alumni on the other hand stated "professional identity" as most important learning outcome followed with "interprofessionalism", "learning environment" and "uniprofessionalism". The study indicated that over time the perceived outcome of learning experiences from an ITU change in priority.

Introduction: The purpose of this study was to assess the coherence between the undergraduate medical program at Aarhus University and the foundation year., Material and Methods: This cross-sectional questionnaire survey included 503 doctors graduated from Aarhus University from the winter of 2007/2008 to the summer of 2009., Results: The response rate was 73%. Approximately 73% of the respondents were in their foundation year or their first year of specialist training and 83% generally felt well-prepared. Respondents found that most of the learning outcomes of the undergraduate medical curriculum at Aarhus University are important for junior doctors. More than 90% of the respondents estimated that they were sufficiently prepared when it came to core outcomes such as history taking and physical examination. Five issues diverged considerably in importance stated and preparedness experienced: suggestion of diagnoses, initiation of treatment, pharmacotherapy, handling of own emotions and structuring of own learning. Also, 40% stated that their clerkships had only had little value in preparing them for their foundation year., Conclusion: Overall, graduates felt well-prepared and characterized the education coherent. However, the study raises major questions concerning clerkships and competence in treatments, pharmacotherapy and the more personal aspects of professionalism., Funding: not relevant., Trial Registration: not relevant.

Context: Very few studies have reported on the effect of admission tests on medical school dropout. The main aim of this study was to evaluate the predictive validity of non-grade-based admission testing versus grade-based admission relative to subsequent dropout., Methods: This prospective cohort study followed six cohorts of medical students admitted to the medical school at the University of Southern Denmark during 2002-2007 (n=1544). Half of the students were admitted based on their prior achievement of highest grades (Strategy 1) and the other half took a composite non-grade-based admission test (Strategy 2). Educational as well as social predictor variables (doctor-parent, origin, parenthood, parents living together, parent on benefit, university-educated parents) were also examined. The outcome of interest was students' dropout status at 2 years after admission. Multivariate logistic regression analysis was used to model dropout., Results: Strategy 2 (admission test) students had a lower relative risk for dropping out of medical school within 2 years of admission (odds ratio 0.56, 95% confidence interval 0.39-0.80). Only the admission strategy, the type of qualifying examination and the priority given to the programme on the national application forms contributed significantly to the dropout model. Social variables did not predict dropout and neither did Strategy 2 admission test scores., Conclusions: Selection by admission testing appeared to have an independent, protective effect on dropout in this setting., (© Blackwell Publishing Ltd 2011.)

Context: Medical school dropout may have negative consequences for society, patients, the profession, schools and dropouts. To our knowledge, the literature dealing with dropout from medical school has never been systematically and critically appraised., Objectives: This review aimed to systematically and critically review studies dealing with factors found to be associated with dropping out of medical school., Methods: A systematic critical literature review of the international peer-reviewed research literature on medical education was performed. A primary search was conducted and subsequently supplemented with ancestry and descendancy searches. The population of interest was medical students and the outcome was dropout. Abstract/title screening and quality assessment were performed by two independent researchers. Studies were assessed on six domains of quality: study participation; study attrition; predictor measurement; measurement of and accounting for confounders; outcome measurement, and analysis. Only studies that accounted for confounding were included in the final analysis., Results: Of 625 studies found, 48 were quality-assessed and 13 of these were eventually included based on their fulfilment of our quality-related criteria. A range of entry qualifications seemed to be associated with greater chances of a student dropping out (odds ratio [OR] = 1.65-4.00). Struggling academically in medical school may be strongly associated with dropout. By contrast, no specific pattern of demographic variables was particularly important in relation to dropout. The effects of socio-economic, psychological and educational variables on dropout were not well investigated., Conclusions: More research into causal models and theory testing, which considers the effects of education, organisation and institution, is necessary if we are to learn more about how we can actively prevent medical student withdrawal., (© Blackwell Publishing Ltd 2011.)

Background: Junior physicians are sometimes sent in ambulances with critically ill patients who require urgent transfer to another hospital. Unfamiliar surroundings and personnel, time pressure, and lack of experience may imply a risk of insufficient treatment during transportation as this can cause the physician to loose the expected overview of the situation. While health care professionals are expected to follow complex algorithms when resuscitating, stress can compromise both solo-performance and teamwork., Aim: To examine whether inter-hospital resuscitation improved with a structured team briefing between physician and ambulance crew in preparation for transfer vs. review of resuscitation guidelines. The effect parameters were physician team leadership (requesting help, delegating tasks), time to resuscitation key elements (chest compressions, defibrillation, ventilations, medication, or a combination of these termed "the first meaningful action"), and hands-off ratio., Participants: 46 physicians graduated within 5 years., Design: A simulation intervention study with a control group and two interventions (structured team briefing or review of guidelines). Scenario: Cardiac arrest during simulated inter-hospital transfer., Results: Forty-six candidates participated: 16 (control), 13 (review), and 17 (team briefing). Reviewing guidelines delayed requesting help to 162 seconds, compared to 21 seconds in control and team briefing groups (p = 0.021). Help was not requested in 15% of cases; never requesting help was associated with an increased hands-off ratio, from 39% if the driver's assistance was requested to 54% if not (p < 0.01). No statistically significant differences were found between groups regarding time to first chest compression, defibrillation, ventilation, drug administration, or the combined "time to first meaningful action"., Conclusion: Neither review nor team briefing improved the time to resuscitation key elements. Review led to an eight-fold increase in the delay to requesting help. The association between never requesting help and an increased hands-off ratio underpins the importance of prioritising available resources. Other medical and non-medical domains have benefited from the use of guidelines reviews and structured team briefings. Reviewing guidelines may compromise the ability to focus on aspects such as team leading and delegating tasks and warrants the need for further studies focusing on how to avoid this cognitive impairment.

Purpose: To enhance the recognition of educational effort and thereby support faculty vitality, the authors aimed to identify essential categories of educational effort from the perspective of clinical faculty and determine whether the emerging categories were in concordance with an organizational perspective., Method: The authors performed nominal group processes in four groups in 2008, with the participation of 24 clinical faculty members, 6 in each group, representing 18 (medical, surgical, paraclinical, and psychiatric) specialties at 14 hospitals in Denmark. Subsequently, the authors performed a comparative analysis of the emerging essential categories and the organizational work by the national panel on medical education, appointed by the Association of American Medical Colleges (AAMC)., Results: The four groups of clinical faculty members agreed on categories of educational effort. This quantitative consistency in prioritization was supported by qualitative consistency, as the authors observed similar uses of words and phrases among all four groups. The top priority in essential categories of educational effort was "Visibility of planned educational activities on the work schedule," which received 39% of all votes. The comparative analysis showed that the essential categories of educational effort suggested by clinical faculty were in concordance with the steps developed by the AAMC., Conclusions: The high degree of consistency among clinical faculty from different locations and specialties and the high concordance with the organizational work of the AAMC suggest that it is possible to develop standardized measurements of educational effort. Clinical faculty emphasized that a good starting point for educational measurements is the work schedule.

Background: The importance of circulation during cardiopulmonary resuscitation has led to efforts to decrease time without chest compressions ("no-flow time"). The no-flow time from the interruption of chest compressions until defibrillation is referred to as the "pre-shock pause". A shorter pre-shock pause increases the chance of successful defibrillation. It is unclear whether drug administration affects the length of the pre-shock pause. Our study compares pre-shock pause with and without drug administration in a full-scale simulation., Methods: This was an observational study in an ambulance including 72 junior physicians and a cardiac arrest scenario. Data were extracted by reviewing video recordings of the resuscitation. Sequences including defibrillation and/or drug administration were identified and assigned to one out of four categories: Defibrillation only (DC-only) and drug administration just prior to defibrillation (Drug+DC) for which the pre-shock pause was calculated, and drug administration alone (Drug-only) for which pre-drug time was calculated., Results: DC-only sequences were identified in 68/72 simulations, Drug+DC in 24/72, and Drug-only in 33/72. Median pre-shock pauses were 18s (DC-only) and 32 (Drug+DC), and median pre-drug pause 6. The variation between pauses was statistically significant (p<<0.001). DC-only and Drug+DC sequences was found in 22/72 simulations. A statistically significant difference of 8s was found between the median pre-shock pauses: 17s (DC-only) and 25 (Drug+DC) (p<<0.001). For un-paired observations, the pre-shock pause increased with 78% and for paired observations 47%., Conclusions: Drug administration prior to defibrillation was associated with significant increases in pre-shock pauses in this full-scale simulation study., (Copyright 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Newly qualified doctors are expected to be able to conduct a cardiac auscultation unassisted, but studies show conflicting results regarding cardiac auscultation skills., Methods: A two-part test instrument was designed containing innovative recordings of heart sounds from patients with common cardiac murmurs as well as healthy controls. A total number of 109 participants were tested, representing four levels of clinical experience. The content validity of the test instrument was studied by a postal questionnaire to 114 clinical teachers at the University Hospital of Aarhus, Denmark., Results: A significant correlation was found between level of experience and the ability to diagnose the conditions from which the murmurs originated (r = 0.45, P < 0.0001). No correlation was found between level of experience and the ability to identify persons with cardiac murmurs from healthy controls. All groups showed a tendency to interpret healthy heart sounds as cardiac murmurs., Conclusions: Diagnostic ability was found to correlate positively with clinical experience, whereas the ability to distinguish cardiac murmurs from normal heart sounds seems independent of clinical experience.

Purpose: Non-cognitive admission criteria are typically used in chiropractic student selection to supplement grades. The reliability of non-cognitive student admission criteria in chiropractic education has not previously been examined. In addition, very few studies have examined the overall test generalizability of composites of non-cognitive admission variables in admission to health science programs. The aim of this study was to estimate the generalizability of a composite selection to a chiropractic program, consisting of: application form information, a written motivational essay, a common knowledge test, and an admission interview., Methods: Data from 105 Chiropractic applicants from the 2007 admission at the University of Southern Denmark were available for analysis. Each admission parameter was double scored using two random, blinded, and independent raters. Variance components for applicant, rater and residual effects were estimated for a mixed model with the restricted maximum likelihood method. The reliability of obtained applicant ranks (generalizability coefficients) was calculated for the individual admission criteria and for the composite admission procedure., Results: Very good generalizability was found for the common knowledge test (G=1.00) and the admission interview (G=0.88). Good generalizability was found for application form information (G=0.75) and moderate generalizability (G=0.50) for the written motivation essay. The generalizability of the final composite admission procedure, which was a weighted composite of all 4 admission variables was good (G(c) = 0.80)., Conclusion: Good generalizability for a composite admission to a chiropractic program was found. Optimal weighting and adequate sampling are important for obtaining optimal generalizability. Limitations and suggestions for future research are discussed.

Introduction: Physicians are expected to manage their role as teamleader during resuscitation. During inter-hospital transfer the physician has the highest medical credentials on a small team. The aim of this study was to describe physician behaviour as teamleaders in a simulated cardiac arrest during inter-hospital transfer. Our goal was to pinpoint deficits in knowledge and skill integration and make recommendations for improvements in education., Method: An ambulance was the framework for the simulation; the scenario a patient with acute coronary syndrome suffering ventricular fibrillation during transportation. Physicians (graduation age < or =5 years) working in internal medicine departments in Denmark were studied. The ambulance crew was instructed to be passive to clarify the behaviour of the physicians., Results: 72 physicians were studied. Chest compressions were initiated in 71 cases, ventilation and defibrillation in 72. The median times for arrival of the driver in the patient cabin, initiation of ventilation and chest compressions, and first defibrillation were all less than 1min. Medication was administered in 63/72 simulations (88%), after a median time of 210 s. Adrenaline was the preferred initial drug administered (58/63, 92%). Tasks delegated were ventilations, chest compressions, defibrillation, and administration of medication (97%, 92%, 42%, and 10% of cases, respectively)., Discussion and Conclusion: Junior physicians performed well with respect to the treatment given and the delegation of tasks. However, variations in the time of initiation it took for each treatment indicated lack of leadership skills. It is imperative that the education of physicians includes training in leadership.

Unlabelled: OBJECTIVES The reliability of individual non-cognitive admission criteria in medical education is controversial. Nonetheless, non-cognitive admission criteria appear to be widely used in selection to medicine to supplement the grades of qualifying examinations. However, very few studies have examined the overall test generalisability of composites of non-cognitive admission variables in medical education. We examined the generalisability of a composite process for selection to medicine, consisting of four variables: qualifications (application form information); written motivation (in essay format); general knowledge (multiple-choice test), and a semi-structured admission interview. The aim of this study was to estimate the generalisability of a composite selection., Methods: Data from 307 applicants who participated in the admission to medicine in 2007 were available for analysis. Each admission parameter was double-scored using two random, blinded and independent raters. Variance components for applicant, rater and residual effects were estimated for a mixed model with the restricted maximum likelihood (REML) method. The reliability of obtained applicant ranks (G coefficients) was calculated for individual admission criteria and for composite admission procedures., Results: A pre-selection procedure combining qualification and motivation scores showed insufficient generalisability (G = 0.45). The written motivation in particular, displayed low generalisability (G = 0.10). Good generalisability was found for the admission interview (G = 0.86), and for the final composite selection procedure (G = 0.82)., Conclusions: This study revealed good generalisability of a composite selection, but indicated that the application, composition and weighting of individual admission variables should not be random. Knowledge of variance components and generalisability of individual admission variables permits evidence-based decisions on optimal selection strategies.

A recent publication demonstrated the possibility of erroneous operation of 2 widely used monitor-defibrillators and observed that the design of user interfaces might contribute to error during operation. During an ambulance simulation training exercise for 72 junior internal medicine physicians that called for defibrillation in the management of cardiac arrest, we observed that in 5 of 192 defibrillation attempts by the physicians, the monitor-defibrillator was inadvertently powered off. When the device is inadvertently powered off, recognition and subsequent steps to defibrillate delayed defibrillation an average of 24 seconds (range 14 to 32 seconds). Our analysis of the controls of this monitor-defibrillator found that the device could be powered off even if fully charged and ready to shock. Redesign of the equipment might prevent this inadvertent event.

Objective: To understand core curriculum design and involvement of stakeholders., Methods: Twelve homogeneous focus group interviews with a total of 88 students, house officers, senior doctors and nurses concerning an undergraduate emergency medicine curriculum. Following content coding of transcripts, we analysed by condensation, categorisation and qualitative content analyses., Results: The focus group participants gave a range of reasons for defining objectives or outcomes. They found their involvement in the process essential. Their argumentation and beliefs differed significantly, revealing 2 opposite perspectives: objectives as context-free theory-based rules versus objectives as personal practice-based guidelines. The students favoured theory-based objectives, which should be defined by experts conclusively as minimum levels and checklists. The senior doctors preferred practice-based objectives, which should be decided in a collaborative, local, continuous process, and should be expressed as ideals and expectations. The house officers held both perspectives. Adding to complexity, participants also interpreted competence inconsistently and mixed concepts such as knowledge, observation, supervision, experience and expertise., Discussion: Participating novices' perspectives on objectives differed completely from expertise level participants. These differences in perspectives should not be underestimated, as they can lead easily to misunderstandings among stakeholders, or between stakeholders, educational leaders and curriculum designers. We recommend that concepts are discussed with stakeholders in order to reach a common understanding and point of departure for discussing outcomes. Differences in perspectives, in our opinion, need to be recognised, respected and incorporated into the curriculum design process.

Context: During the third semester of a 6-year long curriculum medical students train clinical skills in the skills laboratory (2 hours per week for 9 weeks) as well as in an early, 8-week clinical clerkship at county hospitals., Objectives: to study students' expectations and attitudes towards skills training in the skills laboratory and clerkship., Subjects: 126 medical students in their 3 rd semester., Methods: During the fall of 2001 three consecutive, constructed questionnaires were distributed prior to laboratory training, following laboratory training but prior to clerkships, and following clerkships respectively., Results: Almost all (98%) respondents found that training in skills laboratory improved the outcome of the early clerkship and 70% believed in transferability of skills from the laboratory setting to clerkship. Still, a majority (93%) of students thought that the clerkship provided students with a better opportunity to learn clinical skills when compared to the skills laboratory. Skills training in laboratory as well as in clerkship motivated students for becoming doctors. Teachers in both settings were perceived as being committed to their teaching jobs, to demonstrate skills prior to practice, and to give students feed back with a small but significant more positive rating of the laboratory. Of the 22 skills that students had trained in the laboratory, a majority of students tried out skills associated with physical examination in the clerkship, whereas only a minority of students tried out more intimate skills. Female medical students tried significantly fewer skills during their clerkship compared to male students., Conclusions: Students believe that skills laboratory training prepare them for their subsequent early clerkship but favor the clerkship over the laboratory.

Objective: To compare and contrast the learned and an intended curricula of practical clinical skills across the three Danish medical schools., Context: The three Danish medical schools had comparable discipline-based curricula with 3 years of mainly basic science and 3(1/2) years of mainly clinical education. Danish physicians work as pre-registration house officers (PRHOs) for 1(1/2) years after graduation., Methods: An anonymous questionnaire listing 210 practical clinical skills was mailed to 226 newly graduated Danish physicians. They were asked if they could meet the minimum level for each of the skills listed as identified by a previous Delphi study., Results: The response rate was 80%. None of the responders met the minimum of all the 210 skills. Only 8% (14) met the minimum level for at least 90% (189) of the skills. On average the responders met the minimum of 74% (155) of the skills. More than 90% of the responders mastered basic history and examination skills. The responders did not meet 28 medical emergency procedures., Conclusions: We found that the learned curriculum of clinical skills constituted 75% of the intended curriculum. Those responsible for pre- and postgraduate medical education should be aware of the discrepancy between expected and learned curriculum. We discuss the role of experts in the process of defining the core curriculum.

Micturition can be characterized experimentally by monitoring both the frequency and volume of micturition. Previous studies demonstrated that the functional capacity of the rat and rabbit bladder, as determined by cystometry, is approximately equal to the maximal single micturition volume as recorded over a 24 hour period. Studies in many laboratories have demonstrated that chronic increases in diuresis induce increases in micturition frequency and capacity, and an increase in bladder mass. The current study compares the temporal relationship among these parameters in three models of diuresis: streptozotocin-induced diabetes in rats, sucrose-induced diuresis in rats, and furosemide-induced diuresis in rabbits. In both sucrose diuresis in rats and furosemide diuresis in rabbits there were immediate increases in both the frequency and volume of micturition. The magnitude of the increases in micturition frequency and micturition volume paralleled the increase in the total volume of urine excreted. Bladder mass increased progressively over the time course of the study. Streptozotocin-induced diabetes resulted in a more gradual (but parallel) increase in micturition frequency and volume, and again a more gradual increase in bladder mass. These studies demonstrate that functional bladder capacity is increased immediately upon the initiation of diuresis with sucrose or furosemide, as is the frequency of micturition. This indicates that functional bladder capacity is probably under neuronal regulation and the change in capacity is not a function of the increased bladder mass which occurs at a later time period.(ABSTRACT TRUNCATED AT 250 WORDS)