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Prescribing (writing medication orders) is one of residents' commonest tasks. Superficially, all they have to do is complete a form. Below this apparent simplicity, though, lies the complex task of framing patients' needs and navigating relationships with them and other clinicians. Mistakes, which compromise patient safety, commonly result. There is no evidence that competence-based education is preventing harm. We found a profound contradiction between medical students becoming competent, as defined by passing competence assessments, and becoming capable of safely caring for patients. We reinstated patients as the object of learning by allowing students to 'pre-prescribe' (complete, but not authorise prescriptions). This turned a disabling tension into a driver of curriculum improvement. Students 'knotworked' within interprofessional teams to the benefit of patients as well as themselves. Refocusing undergraduate medical education on patient care showed promise as a way of improving patient safety.

Background: Non-verbal communication skills (NVCS) help physicians to deliver relationship-centred care, and the effective use of NVCS is associated with improved patient satisfaction, better use of health services and high-quality clinical care. In contrast to verbal communication skills, NVCS training is under developed in communication curricula for the health care professions. One of the challenges teaching NVCS is their tacit nature. In this study, we evaluated drama exercises to raise awareness of NVCS by making familiar activities 'strange'., Methods: Workshops based on drama exercises were designed to heighten an awareness of sight, hearing, touch and proxemics in non-verbal communication. These were conducted at eight medical education conferences, held between 2014 and 2016, and were open to all conference participants. Workshops were evaluated by recording narrative data generated during the workshops and an open-ended questionnaire following the workshop. Data were analysed qualitatively, using thematic analysis. Non-verbal communication skills help doctors to deliver relationship-centred care RESULTS: One hundred and twelve participants attended workshops, 73 (65%) of whom completed an evaluation form: 56 physicians, nine medical students and eight non-physician faculty staff. Two themes were described: an increased awareness of NVCS and the importance of NVCS in relationship building. Drama exercises enabled participants to experience NVCS, such as sight, sound, proxemics and touch, in novel ways. Participants reflected on how NCVS contribute to developing trust and building relationships in clinical practice., Discussion: Drama-based exercises elucidate the tacit nature of NVCS and require further evaluation in formal educational settings., (© 2018 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Peer-assisted learning (PAL) increasingly features within medical school curricula. While there is evidence of its effectiveness, less is known about how it promotes learning. Cognitive and social congruence between peer-tutor and student have been described as important concepts underpinning teaching and learning in PAL. We employed interpretative phenomenological analysis for an in-depth exploration of how medical students experience PAL sessions., Methods: We conducted the study at The University of Manchester within a near-peer scheme aimed at developing clinical skills within clinical clerkship students. We conducted individual interviews with three peer tutors and five students. We undertook interpretive phenomenological analysis of interview transcripts. We subsequently synthesised an account of the study participants' lived experiences of PAL sessions from individual personal accounts to explore how medical students experience peer-assisted learning. This analysis was then used to complement and critique a priori educational theory regarding the mechanisms underlying PAL., Results: Students experienced PAL sessions as a safe and egalitarian environment, which shaped the type and style of learning that took place. This was facilitated by close relationships with peer-tutors, with whom they shared a strong sense of camaraderie and shared purpose. Peer-tutors felt able to understand their students' wider sociocultural context, which was the most important factor underpinning both the PAL environment and tutor-student relationship. Participants contrasted this relative safety, camaraderie and shared purpose of PAL with teaching led by more senior tutors in clinical settings., Conclusions: This study provides a rich description of the important factors that characterise medical students' experiences of PAL sessions. Participants felt a strong sense of support in PAL sessions that took into account their wider sociocultural context. Multiple factors interplayed to create a learning environment and tutor-student relationship that existed in contrast to teaching led by more senior, clinical tutors. The insight generated via IPA complemented existing theory and raised new lines of enquiry to better understand how the peer relationship fosters learning in PAL at medical school. We make recommendations to use insights from PAL for faculty and curriculum development.

Context: The use of point-of-care ultrasound (POCUS) in clinical care is growing rapidly and advocates have recently proposed the integration of ultrasound into undergraduate medical education (UME). The evidentiary basis for this integration has not been evaluated critically or systematically., Objectives: We conducted a critical and systematic review framed by the rationales enumerated in academic publications by advocates of ultrasound in UME., Methods: This research was conducted in two phases. First, the dominant discursive rationales for the integration of ultrasound in UME were identified from an archive of 403 academic publications using techniques from Foucauldian critical discourse analysis (CDA). We then sought empirical evidence in support of these rationales, using a critical synthesis methodology also adapted from CDA., Results: We identified four dominant discursive rationales with different levels of evidentiary support. The use of ultrasound was not demonstrated to improve students' understanding of anatomy. The benefit of ultrasound in teaching physical examination was inconsistent and rests on minimal evidence. With POCUS, students' diagnostic accuracy was improved for certain pathologies, but findings were inconsistent for others. Finally, the rationale that ultrasound training in UME will improve the quality of patient care was difficult to evaluate., Conclusions: Our analysis has shown that the frequently repeated rationales for the integration of ultrasound in UME are not supported by a sufficient base of empirical research. The repetition of these dominant discursive rationales in academic publications legitimises them and may preclude further primary research. As the value of clinical ultrasound use by medical students remains unproven, educators must consider whether the associated financial and temporal costs are justified or whether more research is required., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Prescribing tasks, which involve pharmacological knowledge, clinical decision-making and practical skill, take place within unpredictable social environments and involve interactions within and between endlessly changing health care teams. Despite this, curriculum designers commonly assume them to be simple to learn and perform. This research used mixed methods to explore how undergraduate medical students learn to prescribe in the 'real world'. It was informed by cognitive psychology, sociocultural theory, and systems thinking. We found that learning to prescribe occurs as a dynamic series of socially negotiated interactions within and between individuals, communities and environments. As well as a thematic analysis, we developed a framework of three conceptual spaces in which learning opportunities for prescribing occur. This illustrates a complex systems view of prescribing education and defines three major system components: the "social space", where the environmental conditions influence or bring about a learning experience; the "process space", describing what happens during the learning experience; and the intra-personal "cognitive space", where the learner may develop aspects of prescribing expertise. This conceptualisation broadens the scope of inquiry of prescribing education research by highlighting the complex interplay between individual and social dimensions of learning. This perspective is also likely to be relevant to students' learning of other clinical competencies.

Clinical clerks learn more than they are taught and not all they learn can be measured. As a result, curriculum leaders evaluate clinical educational environments. The quantitative Dundee Ready Environment Measure (DREEM) is a de facto standard for that purpose. Its 50 items and 5 subscales were developed by consensus. Reasoning that an instrument would perform best if it were underpinned by a clearly conceptualized link between environment and learning as well as psychometric evidence, we developed the mixed methods Manchester Clinical Placement Index (MCPI), eliminated redundant items, and published validity evidence for its 8 item and 2 subscale structure. Here, we set out to compare MCPI with DREEM. 104 students on full-time clinical placements completed both measures three times during a single academic year. There was good agreement and at least as good discrimination between placements with the smaller MCPI. Total MCPI scores and the mean score of its 5-item learning environment subscale allowed ten raters to distinguish between the quality of educational environments. Twenty raters were needed for the 3-item MCPI training subscale and the DREEM scale and its subscales. MCPI compares favourably with DREEM in that one-sixth the number of items perform at least as well psychometrically, it provides formative free text data, and it is founded on the widely shared assumption that communities of practice make good learning environments.

Dealing with emotions is a critical feature of professional behaviour. There are no comprehensive theoretical models, however, explaining how medical students learn about emotions. We aimed to explore factors affecting their emotions and how they learn to deal with emotions in themselves and others. During a first-year nursing attachment in hospitals and nursing homes, students wrote daily about their most impressive experiences, explicitly reporting what they felt, thought, and did. In a subsequent interview, they discussed those experiences in greater detail. Following a grounded theory approach, we conducted a constant comparative analysis, collecting and then interpreting data, and allowing the interpretation to inform subsequent data collection. Impressive experiences set up tensions, which gave rise to strong emotions. We identified four 'axes' along which tensions were experienced: 'idealism versus reality', 'critical distance versus adaptation', 'involvement versus detachment' and 'feeling versus displaying'. We found many factors, which influenced how respondents relieved those tensions. Their personal attributes and social relationships both inside and outside the medical community were important ones. Respondents' positions along the different dimensions, as determined by the balance between attributes and tensions, shaped their learning outcomes. Medical students' emotional development occurs through active participation in medical practice and having impressive experiences within relationships with patients and others on wards. Tensions along four dimensions give rise to strong emotions. Gaining insight into the many conditions that influence students' learning about emotions might support educators and supervisors in fostering medical students' emotional and professional development.

Purpose: To explore how undergraduate medical students learn from real patients in practice settings, the factors that affect their learning, and how clerkship learning might be enhanced., Method: In 2009, 22 medical students in the three clerkship years of an undergraduate medical program in the United Kingdom made 119 near-contemporaneous audio diary entries reflecting how they learned from real patients. Nineteen attended focus groups; 18 were individually interviewed. The authors used a qualitative theory-building methodology with a conceptual orientation toward Communities of Practice theory. A learning theorist guided selective coding of a constant-comparative analysis., Results: Participants learned informally by participating in the communicative practices of workplaces. Two overlapping practices, patient care and education, were identified. Patient care created learning opportunities, which were enriched when practitioners intentionally supported participants' learning. Education, however, was not always coupled with patient care. So, talk positioned the boundaries of two practices in three configurations: education without patient care, education within patient care, and patient care without education. The nature and quality of participants' learning depended on how practitioners entered dialogue with them and linked the dialogue to authentic patient care., Conclusions: Findings strongly suggest that medical students learn from real patients by participating in patient care within an educational practice. Their learning is affected by clinicians' willingness to engage in supportive dialogue. Promoting an informal, inclusive discourse of workplace learning might enhance clerkship education. This approach should take its place alongside-and perhaps ahead of-the currently dominant discourse of "clinical teaching."

"Curricula-in-action" generally differ from "official" curricula. That is particularly true of clerkship curricula because the practising doctors who supervise medical students' clinical activities are only secondarily educators. Clerkship education is evaluated, however, according to benchmarks set by official curricula. As a result, clerkship evaluations are important points of contact between clinical teachers and medical schools. We reasoned that an evaluation instrument is part of a medical school's official curriculum discourse and clinical teachers' reactions to it are a discourse of curriculum-in-action. We set out to answer the questions: What are clinical teachers' discourses of curriculum-in-action and how do they relate to an official curriculum discourse? Nineteen clerkship placement leads from two hospitals contributing to a single undergraduate medical programme participated. The evaluation instrument was the Manchester Clinical Placement Index, for which validity evidence has been published. Respondents were asked to say how they would react to junior students giving their placements low or high scores for each of 12 items from the Index. After transcription, we conducted a critical discourse analysis (CDA) of their audio-recorded answers. We purposefully selected the six items that elicited the widest spectrum of responses for analysis because quantity of material can compromise the quality of CDA. A dominant discourse of curriculum-in-action defined how teachers should "really" teach and junior students should learn. It deconstructed the need for teachers to be present when students performed clinical tasks because teachers' role was to give critical feedback on case presentations that were coincidental to clinical care. It positioned students at the bottom of a power hierarchy so they had to "struggle" to be taught. It placed respondents in a powerful position relative to "the hospital" and "the university", though there were tensions between respondents, patients, and nurses. Respondents dismissed criticism that was invalid according to their curriculum-in-action, which included most items in an evaluation instrument. There was a contrasting, non-dominant discourse of responding reflectively to feedback, which generated realistic ways of improving students' learning. The strength of respondents' emotions shows just how committed doctors are to students' learning. The strength of their expressions of power, however, explains why many of them teach in their own way rather than according to official curricula. Changes to clinical curricula, our findings suggest, will not be successful unless they are carefully negotiated with practising doctors.

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.

This review examines the extent to which undergraduate prescribing education prepares graduates for the complexities of prescribing in the workplace context. In order to prescribe safely, it is important for medical students to acquire prescribing expertise. We have developed a theoretical model, based on theories of expertise development, which acknowledges the inherent complexity of the task itself, the social context and the relationship between the two. We have examined the empirical evidence on educational interventions for prescribing by reviewing the extent to which the interventions acknowledge the different components of our theoretical model. Fifteen empirical studies met our inclusion criteria and were reviewed in detail. All the studies were conducted between 2002 and 2010, six were controlled trials, six were before and after studies and three were prospective observational studies. We found that most studies focused on improving and evaluating students' knowledge and skills, although they used different approaches to doing so. These aspects of prescribing only constitute a small part of our theoretical model of prescribing expertise. Other important components, such as social context, metacognition and training transfer, were neglected. We suggest that educational interventions need to account for the integrated nature of learning to prescribe and take a more contextualized approach which considers the task as a whole, rather than isolated constituent parts. In doing so, prescribing education could equip graduates with the necessary expertise to judge and respond to situations, enabling them to prescribe safely, or seek the help to do so, in the unpredictable and complex context of workplaces., (© 2012 The Authors. British J Clin Pharmacol © 2012 The British Pharmacological Society.)

Context: It is important to know how patients are affected by becoming opportunistically involved in medical student education. In previous studies, researchers rather than patients set the research agenda and expert patients or people well known to teachers were more often involved than ordinary people., Objectives: This study aimed to explore how ordinary patients experience undergraduate medical teaching when they become involved in it opportunistically and to derive practical insights from the lived experiences of these patients., Methods: The research was conducted in line with a conceptual orientation towards communities of practice theory and used phenomenology as a way of exploring patients' lived experiences in depth. Minimally structured interviews were carried out with 10 patients following ordinary out-patient or general practice appointments in which students were being taught. Template analysis was used to generate provisional themes and a process of phenomenological reduction was used to distil individual respondents' lived experiences to their essence., Results: The presence of students in ambulatory consultations was normal. Nine respondents described transactional relationships in which they remained outside the community of practice of which the doctor and student were members. Only an intimate problem would engage them deeply enough for a student's presence to 'bother' them. One patient's personal and professional background led her to regard doctors' handling of consultation dynamics as factors contributing to whether teaching consultations were negative or positive experiences. When doctors' sensitive and inclusive behaviour drew her into a triadic relationship with the student and doctor, she experienced mutual benefits with students. When it did not, she felt objectified and alienated., Conclusions: Provided they receive the clinical care for which they are attending a consultation and are treated respectfully, patients may sometimes willingly become 'objects' from which students learn. They may, however, become more deeply engaged in teaching consultations in which they participate actively in a triadic relationship of mutual benefit with a doctor and student. Teaching consultations call for doctors to be sensitive and adaptable., (© Blackwell Publishing Ltd 2012.)

Background: Reflection on professional experience is increasingly accepted as a critical attribute for health care practice; however, evidence that it has a positive impact on performance remains scarce. This study investigated whether, after allowing for the effects of knowledge and consultation skills, reflection had an independent effect on students' ability to solve problem cases., Methods: Data was collected from 362 undergraduate medical students at Ghent University solving video cases and reflected on the experience of doing so. For knowledge and consultation skills results on a progress test and a course teaching consultation skills were used respectively. Stepwise multiple linear regression analysis was used to test the relationship between the quality of case-solving (dependent variable) and reflection skills, knowledge, and consultation skills (dependent variables)., Results: Only students with data on all variables available (n = 270) were included for analysis. The model was significant (Anova F(3,269) = 11.00, p < 0.001, adjusted R square 0.10) with all variables significantly contributing., Conclusion: Medical students' reflection had a small but significant effect on case-solving, which supports reflection as an attribute for performance. These findings suggest that it would be worthwhile testing the effect of reflection skills training on clinical competence.

This manuscript describes the final year of medical education at Maastricht University as it has been operating since 2006. At the time external drivers for the development of a new structure of the final year were: the desire to prepare medical students for lifelong learning, the CanMEDs that were increasingly acknowledged to state the final attainment level of medical education and an increasing recognition of the importance of learning by participating actively and by taking more responsibility. Internal drivers were students' evaluations and our wish to improve instructional design and quality control. The main aim of this new final year is to better prepare students for the transition from the medical master programme to one of the postgraduate training programmes to become a medical specialist. The final year of the medical master programme consists of two 18-weeks participation electives, one in health care and one in research. Students have a higher level of autonomy and responsibility during this final year compared to the preceding medical clerkships to enhance the transition. Portfolios are the key element in examination of SCIP and HELP. Student evaluations of the final year show high scores on coaching and instructiveness. Despite some differences between departments overall scores are very high. Suggestions to improve include the availability of work places and time for education and coaching., (Copyright © 2012. Published by Elsevier GmbH.)

Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is referred to as workplace learning, a complex system in which various factors influence what is being learned and how. A theory that can highlight potential difficulties in this complex learning system about patient safety is activity theory. Thirty-four final year undergraduate medical students participated in four focus groups about their experiences concerning patient safety. Using activity theory as analytical framework, we performed constant comparative thematic analysis of the focus group transcripts to identify important themes. We found eight general themes relating to two activities: learning to be a doctor and delivering safe patient care. Simultaneous occurrence of these two activities can cause contradictions. Our results illustrate the complexity of learning about patient safety at the workplace. Students encounter contradictions when learning about patient safety, especially during a transitional phase of their training. These contradictions create potential learning opportunities which should be used in education about patient safety. Insight into the complexities of patient safety is essential to improve education in this important area of medicine.

Context: Conceptualisations of self-assessment are changing as its role in professional development comes to be viewed more broadly as needing to be both externally and internally informed through activities that enable access to and the interpretation and integration of data from external sources. Education programmes use various activities to promote learners' reflection and self-direction, yet we know little about how effective these activities are in 'informing' learners' self-assessments., Objectives: This study aimed to increase understanding of the specific ways in which undergraduate and postgraduate learners used learning and assessment activities to inform self-assessments of their clinical performance., Methods: We conducted an international qualitative study using focus groups and drawing on principles of grounded theory. We recruited volunteer participants from three undergraduate and two postgraduate programmes using structured self-assessment activities (e.g. portfolios). We asked learners to describe their perceptions of and experiences with formal and informal activities intended to inform self-assessment. We conducted analysis as a team using a constant comparative process., Results: Eighty-five learners (53 undergraduate, 32 postgraduate) participated in 10 focus groups. Two main findings emerged. Firstly, the perceived effectiveness of formal and informal assessment activities in informing self-assessment appeared to be both person- and context-specific. No curricular activities were considered to be generally effective or ineffective. However, the availability of high-quality performance data and standards was thought to increase the effectiveness of an activity in informing self-assessment. Secondly, the fostering and informing of self-assessment was believed to require credible and engaged supervisors., Conclusions: Several contextual and personal conditions consistently influenced learners' perceptions of the extent to which assessment activities were useful in informing self-assessments of performance. Although learners are not guaranteed to be accurate in their perceptions of which factors influence their efforts to improve performance, their perceptions must be taken into account; assessment strategies that are perceived as providing untrustworthy information can be anticipated to have negligible impact., (© Blackwell Publishing Ltd 2011.)

Objectives: This study aimed to explore how medical students experience contacts with real patients and what they learn from them., Methods: We carried out a post hoc, single-group study in one teaching sector of a 5-year, problem-based, horizontally integrated, outcome-based and community-oriented undergraduate programme, in which students lacked clinical exposure in the pre-clerkship phase. Subjects comprised five cohorts of students on their first clerkships. Data consisted of purposively selected, voluntary, self-report statements regarding real patient learning (RPL). Constant comparative analysis was performed by two independent researchers., Results: Respondents valued patients as an instructional resource that made learning more real. They reported learning through visual pattern recognition as well as through dialogue and physical examination. They more often used social than professional language to describe RPL. They reported affective outcomes including enhanced confidence, motivation, satisfaction and a sense of professional identity. They also reported cognitive outcomes including perspective, context, a temporal dimension, and an appreciation of complexity. Real patient learning helped respondents link theory learned earlier with reality as represented by verbal, visual and auditory experiences. It made learning easier, more meaningful and more focused. It helped respondents acquire complex skills and knowledge. Above all, RPL helped learners to remember subject matter. Most negative responses concerned the difficulty of acquiring appropriate experience, but RPL made a minority of respondents feel uncomfortable and incompetent., Conclusions: Real patient learning led to a rich variety of learning outcomes, of which at least some medical students showed high metacognitive awareness. Sensitivity from clinical mentors towards the positive and negative outcomes of RPL reported here could support reflective clinical learning.

Background: Medical education has been characterized in terms of points of transition, which are accentuated by lack of relevant prior experience and can lead to extreme positive and negative emotions., Aims: Quantify the effect of maturity on medical students' transitions into the clinical environment and identify how experiences of transition might be improved., Method: Eleven weeks after entering the clinical environment, 29 mature students (age over 21 at entry, median age 22) in a horizontally-integrated, predominantly undergraduate entry, problem-based curriculum offering little early clinical exposure and 58 matched non-mature students (median age 18 years) rated their experiences of transition and wrote free text comments about them., Results: 62% of mature students compared with 24% of controls described 'good transitions' (odds ratio [OR] for a good transition 6.1; p = 0.002) and mature students were more likely than controls to describe how they drew on their previous years in medical school (OR 2.7, p = 0.04) and their wider life experiences in making the transition (OR 3.9, p = 0.01). They were less likely to feel confused or daunted. Whether mature or not, prior workplace experience, having learned the theory of medicine by PBL, and being confident in their knowledge and skills helped students' transitions. Both mature and non-mature students valued the support of teachers and peers and would have valued clinical experience earlier., Conclusions: The fact that just a few extra years of life experience made such a large difference to students' experiences of transition illustrates how important social factors are in the personal development of medical students. In respondents' views, early clinical experience and early skills training could ease students' passage into the clerkship phase of their education.

UK continuing education is moving from credit-earning, taught continuing medical education (CME) to a continuing professional development (CPD) system that explicitly links education to change in practice, managed and monitored through mandatory peer appraisal. Alongside multisource feedback and consideration of issues of poor performance, satisfactory personal development planning will be required for relicensure and recertification. That system gives self-assessment, in the guise of reflection, a central place in personal development. This article uses instances of directed self-assessment drawn from undergraduate and early postgraduate medical education to consider how a positive system of self-assessment and professional self-regulation could be operationalized. It explores why medical students made avid use of an e-technology that presents the intended outcomes of their problem-based curriculum in a way that helps them seek out appropriate clinical opportunities and identify what they learned from them. It contrasts the experience of early postgraduate learners who, presented with a similar e-technology, found it hard to see links between their official curriculum and their day-by-day learning experiences, at least partly because the intended outcomes it offered were remote from what they were actually learning. Any extrapolation to CPD must be very tentative, but I advocate continued exploration of how best to use e-technology to support and structure (ie, direct) self-assessment. Direction could originate from consensus statements and other well-defined external standards when learners lack mastery of a domain. When learners must respond to institutional demands, direction could be provided by corporate goals. In areas of mastery, I propose learners themselves should define personal standards. In areas of difficulty, external assessment would take the place of self-assessment.

Objective: This study aimed to explore the effect of gender on medical students' aspirations., Methods: The study design included purposive sampling and interim data interpretation to guide recruitment of medical students with a wide spectrum of opinions. Data were collected through audio-recorded, semi-structured, in-depth exploratory interviews, which were transcribed verbatim. Qualitative analysis was carried out by a female medical student researcher. Her evolving interpretation was constantly compared against the original data by male (doctor) and female (pharmacist) staff researchers in a systematic search for internal corroboration or disconfirmation. Causal associations consistently present in the data are reported., Results: Six male and six female medical students in Years 3 and 4 shared a wish to achieve a work-life balance that allowed them to devote time to bringing up children while contributing usefully to society as doctors. However, women were readier to compromise professional attainment within their personal work-life balances. Their readiness derived from gendered stereotypes of women's social and professional roles, a lack of female professional role models, womens' greater awareness of the tensions between career and family, various other informal social influences, and a lack of positive career advice to counterbalance these influences., Conclusions: Better career advice and more flexible work opportunities are needed if the two-thirds of medical students who are women are to contribute specialist as well as generalist expertise to the medical workforce.

Objective: To develop a model linking the processes and outcomes of workplace learning., Methods: We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students., Results: To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning., Conclusions: The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Aim: To examine how students' evaluations of the environment, process and outcome of clinical learning interrelated and correlated with assessment results., Method: A post hoc study in the 3rd of 5 years in a student-centred, horizontally integrated, objective-based medical curriculum. In the last week of each module, students evaluated what they had learned and how they had learned it using a previously validated, web-based scale. The interrelationships between scale variables and their relationships with summative assessment results were tested using factor analysis, correlation analysis and stepwise multiple regression analysis., Results: Student evaluation yielded 4 summary measures: 2 reflected learning outcomes ('real patient learning' and 'curriculum coverage'), 1 reflected process ('quality of instruction') and 1 reflected environment ('conditions for learning'). They fitted a causal model according to which instruction, conditions for learning and curriculum coverage favoured real patient learning. Real patient learning was rated higher in women than men, and the measures were associated more strongly in women. Performance in end-of-year summative assessments was predicted strongly by mid-year performance but by no other measure., Conclusions: Students' evaluations of their learning environment and instructional processes correlated with their assessments of 2 outcomes of the curriculum in action: curriculum coverage and real patient learning. There was little shared variance between those measures and students' performance in summative assessments. Given its formative potential, students' evaluation of their curriculum in action could play a useful part in learner-centred clinical education. There is a possibility, which needs further research, that women's evaluations have greater predictive validity than men's. Assessment performance should be regarded not as a solitary gold standard but as just 1 measure of educational outcome.

Objectives: To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence., Design: A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001., Data Sources: Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration., Selection of Studies: All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication., Results: Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations., Conclusion: Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Aim: To characterise the opening of secondary care consultations., Method: We audio-taped 17 first consultations in medical clinics, transcribed them verbatim, and analysed verbal interactions from when the doctor called the patient into the consulting room to when she or he asked clarifying questions., Results: The interviews did not open with the sequence, reported by previous researchers, of 'doctor's soliciting question, patient's opening statement, interruption by the doctor'. Doctors (1) called the patient to the consultation; (2) greeted them; (3) introduced themselves; (4) made a transition to clinical talk; and (5) framed the consultation. They used a referral letter, the case notes, computer records and their prior knowledge of the patient to help frame the consultation, and did so informally and with humour., Conclusion: These 5 steps could help trainees create a context for active listening that is less prone to interruption.

The aim was to find how to use information and communication technology to present the clinical skills content of an undergraduate medical curriculum. Rapid application design was used to develop the product, and technical action research was used to evaluate the development process. A clinician-educator, two medical students, two computing science masters students, two other project workers, and a hospital education informatics lead, formed a design team. A sample of stakeholders took part in requirements planning workshops and continued to advise the team throughout the project. A university hospital had many features that favoured fast, inexpensive, and successful system development: a clearly defined and readily accessible user group; location of the development process close to end-users; fast, informal communication; leadership by highly motivated and senior end-users; devolved authority and lack of any rigidly imposed management structure; cooperation of clinicians because the project drew on their clinical expertise to achieve scholastic goals; a culture of learning and involvement of highly motivated students. A detailed specification was developed through storyboarding, use case diagramming, and evolutionary prototyping. A very usable working product was developed within weeks. "SkillsBase" is a database web application using Microsoft Active Server Pages, served from a Microsoft Windows 2000 Server operating system running Internet Information Server 5.0. Graphing functionality is provided by the KavaChart applet. It presents the skills curriculum, provides a password-protected portfolio function, and offers training materials. The curriculum can be presented in several different ways to help students reflect on their objectives and progress towards achieving them. The reflective portfolio function is entirely private to each student user and allows them to document their progress in attaining skills, as judged by self, peer and tutor assessment, and examinations. Training materials include web links and materials developed locally using pedagogic principles developed by the SkillsBase team. Although the usability of SkillsBase has been proven, uptake of software that has arisen 'bottom-up' from within the curriculum has proved slow. We plan to incorporate the SkillsBase services into a more comprehensive virtual managed learning environment, anticipating that presenting the functionality in an environment that is routinely used by students and teachers will increase uptake and use.

Aim: This study aimed to establish whether and under what conditions medical students can learn in a self-directed manner in the clinical environment., Method: A web-based learning management system brought 66 placement students, in a problem-based learning (PBL) medical curriculum, into closer touch with their clinical learning objectives and ways of achieving them. Free response comments from 16 of them during the 7 weeks they used it, transcripts of group discussions before and after the period of use, and responses from all 66 students to a questionnaire were analysed qualitatively., Results: Students were rarely fully autonomous or subservient. They valued affective and pedagogic support, and relied on teachers to manage their learning environment. With support, they were motivated and able to choose how and when to meet their learning needs. The new system was a useful adjunct., Conclusions: Self-direction, interpreted literally, was a method of learning that students defaulted to when support and guidance were lacking. They found "supported participation" more valuable. Learning in the clinical environment was a social process with as many differences from, as similarities to, PBL.

Aim: To explore how clinicians perceive their roles in problem-based medical education, and how closely those perceptions link to the curriculum they teach., Method: All 14 general physicians in a teaching hospital took part in 6 semistructured discussions, which were analysed phenomenologically., Results: Third year clinical teaching was described in terms that bore little relation to problem-based learning (PBL). Teachers placed great importance on the social dimension of professional learning. They expressed strongly positive affects towards learners and their learning that they found hard to express as PBL tutors. Their narratives of education were remarkably divorced from modern day clinical practice., Conclusions: Problem-based method lacked some important conditions for professional teaching and learning. Traditional apprenticeship is unsustainable under present day conditions of practice. There is a need for new educational methods that help the learner to build a professional identity through social interaction with practitioners.

The aim was to establish how ICT could apply feedback principles to experience based learning. Based on a survey of student and staff requirements, we developed a personalized educational technology ('iSUS') that: (1) Made students clear what they should learn; (2) Helped them meet appropriate real patients; (3) Encouraged reflective feedback; (4) Calculated benchmarks from accumulated feedback; (5) Compared individual students' feedback against those benchmarks; (6) Matched clinical activities to curriculum objectives; (7) Gave feedback to teachers and course leads. Bench testing proved the system usable. During seven weeks of real time use, a whole year group of 111 students feedback on 1183 learning episodes. Five hundred and forty-one (46%) of feedback episodes were self initiated. We have successfully prototyped an application of feedback principles to experience based learning that students seem to find useful.

Objective: To provide a rationale for integrating experience into early medical education ("early experience")., Design: Small group discussions to obtain stakeholders' views. Grounded theory analysis with respondent, internal, and external validation., Setting: Problem based, undergraduate medical curriculum that is not vertically integrated., Participants: A purposive sample of 64 students, staff, and curriculum leaders from three university medical schools in the United Kingdom., Results: Without early experience, the curriculum was socially isolating and divorced from clinical practice. The abruptness of students' transition to the clinical environment in year 3 generated positive and negative emotions. The rationale for early experience would be to ease the transition; orientate the curriculum towards the social context of practice; make students more confident to approach patients; motivate them; increase their awareness of themselves and others; strengthen, deepen, and contextualise their theoretical knowledge; teach intellectual skills; strengthen learning of behavioural and social sciences; and teach them about the role of health professionals., Conclusion: A rationale for early experience would be to strengthen and deepen cognitively, broaden affectively, contextualise, and integrate medical education. This is partly a process of professional socialisation that should start earlier to avoid an abrupt transition. "Experience" can be defined as "authentic human contact in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional."

Aim: To compare the validity of different measures of self-directed clinical learning., Methods: We used a quasi-experimental study design. The measures were: (1) a 23-item quantitative instrument measuring satisfaction with the learning process and environment; (2) free text responses to 2 open questions about the quality of students' learning experiences; (3) a quantitative, self-report measure of real patient learning, and (4) objective structured clinical examination (OSCE) and progress test results. Thirty-three students attached to a single firm during 1 curriculum year in Phase 2 of a problem-based medical curriculum formed an experimental group. Thirty-one students attached to the same firm in the previous year served as historical controls and 33 students attached to other firms within the same module served as contemporary controls. After the historical control period, experimental group students were exposed to a complex curriculum intervention that set out to maximise appropriate real patient learning through increased use of the outpatient setting, briefing and supported, reflective debriefing., Results: The quantitative satisfaction instrument was insensitive to the intervention. In contrast, the qualitative measure recorded a significantly increased number of positive statements about the appropriateness of real patient learning. Moreover, the quantitative self-report measure of real patient learning found high levels of appropriate learning activity. Regarding outpatient learning, the qualitative and quantitative real patient learning instruments were again concordant and changed in the expected direction, whereas the satisfaction measure did not. An incidental finding was that, despite all attempts to achieve horizontal integration through simultaneously providing community attachments and opening up the hospital for self-directed clinical learning, real patient learning was strongly bounded by the specialty interest of the hospital firm to which students were attached. Assessment results did not correlate with real patient learning., Conclusions: Both free text responses and students' quantitative self-reports of real patient learning were more valid than a satisfaction instrument. One explanation is that students had no benchmark against which to rate their satisfaction and curriculum change altered their tacit benchmarks. Perhaps the stronger emphasis on self-directed learning demanded more of students and dissatisfied those who were less self-directed. Results of objective, standardised assessments were not sensitive to the level of self-directed, real patient learning. Despite an integrated curriculum design that set out to override disciplinary boundaries, students' learning remained strongly influenced by the specialty of their hospital firm.

Aim: To help students in a self-directed, problem-based learning (PBL) curriculum learn from a breadth of hospital experience., Methods: Clinical units were asked to identify what clinical activities they could make available to interested students on a 'first-come, first-served' basis. A centralised, electronic system was developed that allowed students to book a fair, but not excessive, share of those learning opportunities. This web-based programme evolved into a comprehensive timetabling system that managed activities for whole classes of students as well as 'sign-ups' booked by individuals., Results: The sign-up system offered 1792 hours/week, or 6 hours/student/week, to the hospital's 291 students of learning opportunities additional to firm-based teaching and learning. There were sign-ups in all major specialties and they included rounds, clinics, theatre/investigation sessions and conferences. Students accessed the system as commonly from outside the hospital as within it, and used it to view their timetables as well as to book learning opportunities. The system was used particularly heavily when examinations were imminent, indicating that students found it supportive to their learning., Conclusions: We have developed an innovative way of providing experience that is relevant to problem-based, integrative clinical education. Students, as judged by their heavy use of it, value the system.

Aims: The aim of this study was to use information and communications technology to present a curriculum of clinical skills in a user-friendly format., Setting: A UK undergraduate medical school with a problem-based curriculum and a strong emphasis on proficiency in clinical skills., Study Design: Case study describing the qualitative analysis of users' requirements and development of a web-based learning portfolio., Evaluation: The study involved direct observation of users during a 'think-aloud' protocol, a validated software users' measurement inventory and a 17-item questionnaire designed to test whether 'SkillsBase' met its users' requirements., Results: Students wanted a clear and flexible presentation of their skills curriculum that was easy to navigate, offered instructional material and standards for self- and peer assessment, offered useful Internet links, allowed them to compare their progress with school standards and peer norms, and could be used as a learning portfolio. During the think-aloud protocol, students made very few errors in data interpretation or navigation, and found SkillsBase easy to learn and aesthetically pleasing to use. They rated it higher on all measures of usability than standard commercial software. The questionnaire showed that it met most aspects of its design specification, although many students were doubtful that they would use its reflective function. It is available for inspection at http://www.skillsbase.man.ac.uk/., Conclusions: SkillsBase meets the design specification for a training and reflective aid to learning clinical skills and is very usable.

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