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In this article, an alternative for Tinto's integration theory of student persistence is proposed and tested. In the proposed theory, time available for individual study is considered a major determinant of both study duration and graduation rate of students in a particular curriculum. In this view, other activities in the curriculum, in particular lectures, constrain self-study time and therefore must have a negative impact on persistence. To test this theory, we collected study duration and graduation rate information of all--almost 14,000 students--enrolling in eight Dutch medical schools between 1989 and 1998. In addition, information was gathered regarding the timetables of each of these curricula in the particular period: lectures hours, hours spent in small-group tutorials, practicals, and time available for self-study. Structural equation modeling was used to study relations among these variables. In line with our predictions, time available for self-study was the only determinant of graduation rate and study duration. Lectures were negatively related to self-study time, negatively related to graduation rate, and positively related to study duration. The results suggest that extensive lecturing may be detrimental in higher education. However, in the curricula employing limited lecturing considerable energy was spent in supporting self-study activities of students and preventing postponement of learning. Given our findings, both activities will likely have large pay offs, in particular in curricula with low graduation rates. (Contains 4 tables and 1 footnote.)

Medical Education 2011: 45: 987-994 Context Medical students often fail to finish medical school within the designated time. An academic dismissal (AD) policy aims to enforce satisfactory progress and to enable early identification and timely support or referral of struggling students. In this study, we assessed whether the implementation of an AD policy improved study progress in the first 2 years of medical school. Additionally, we analysed its effect on the help-seeking behaviour of struggling students. Methods We compared two AD cohorts (entering in 2005 and 2006, respectively) and two non-AD cohorts (entering in 2003 and 2004, respectively) on dropout rates, Year 1 curriculum completion rates and the percentage of students with an optimal study rate (i.e. all modules completed) at 1 and 2 years after enrolment. We also measured the effect on study progress of attending the support meetings offered. Results The AD ( n = 809) and non-AD cohorts ( n = 809) did not differ significantly in dropout rate at 5 months, in Year 1 completion rate at 2 years and in the percentage of optimally performing students at 1 year after enrolment. At 2 years after enrolment, more students from the AD cohorts had left and more non-AD students demonstrated optimal performance, but effect sizes (ESs) for these differences were small. Voluntary support at 4 months was attended by AD students more often than by non-AD students (68.9% versus 39.8%; χ2(1) = 43.95, p < 0.001, ES = 0.29). The AD students who attended the support meetings completed the Year 1 curriculum more often than those who did not (73.4% versus 52.5%; χ2(1) = 10.92, p < 0.001, ES = 0.20). Attending the obligatory support meeting at 7 months had a similar effect (70.5% versus 33.3%; χ2(1) = 13.60, p < 0.001, ES = 0.23). Conclusions The presence of an AD policy did not lead to earlier dropout, higher completion rates or an improved study rate during the first 2 years at medical school. However, uptake of the support offered increased to almost 70%. Although support participants finished the Year 1 curriculum more often than non-participants, the current support system was not sufficient to improve overall study progress. [ABSTRACT FROM AUTHOR]

Medical Education 2011: 45: 1032-1040 Objectives A recent controlled study by our group showed that the dropout rate in the first 2 years of study of medical students selected for entry by the assessment of a combination of non-cognitive and cognitive abilities was 2.6 times lower than that of a control group of students admitted by lottery. The aim of the present study was to compare the performance of these two groups in the clinical phase. Methods A prospective cohort study was performed to compare the performance of 389 medical students admitted by selection with that of 938 students admitted by weighted lottery between 2001 and 2004. Follow-up of these cohorts lasted 5.5-8.5 years. The main outcome measures were the mean grade obtained on the first five discipline-specific clerkships by all cohorts and the mean grade achieved on all 10 clerkships by the cohorts of 2001 and 2002. Results Selected students obtained a significantly higher mean grade during their first five clerkships than lottery-admitted students (mean ± standard error [SE] 7.95 ± 0.03, 95% confidence interval [CI] 7.90-8.00 versus mean ± SE 7.84 ± 0.02, 95% CI 7.81-7.87; p < 0.001). This difference reflected the fact that selected students achieved a grade of ≥ 8.0 1.5 times more often than lottery-admitted students. An analysis of all mean grades awarded on 10 clerkships revealed the same results. Moreover, the longer follow-up period over the clerkships showed that the relative risk for dropout was twice as low in the selected student group as in the lottery-admitted student group. Conclusions The selected group received significantly higher mean grades on their first five clerkships, which could not be attributed to factors other than the selection procedure. Although the risk for dropout before the clinical phase increased somewhat in both groups, the actual dropout rate proved to be twice as low in the selected group. [ABSTRACT FROM AUTHOR]

Aim: A need was felt to improve the quality of admission and licensing procedures for international medical graduates in The Netherlands. Method: A clinical skills assessment was designed as part of a new procedure to realize a high-stakes, fair, transparent, and a time-limited path of admission for international medical graduates to the Dutch health care system. Additionally, it should provide a well-founded advice about length and content of additional medical training, should this be indicated by the outcome of the assessment. Results: The clinical skills assessment procedure was developed as a Dutch variant of the “Step 2 Clinical Skills examination” of the Educational Commission for Foreign Medical Graduates (ECFMG) in collaboration with the United States National Board of Medical Examiners, which has a well-documented validity and reliability. The experience with the new procedure is yet limited, but enough to warrant a report. Discussion: Worldwide, a number of countries have developed such high-stake assessment procedures, but they show little uniformity and transparency. By describing the design and development of our procedure, we do not pretend to set a standard, but we hope to contribute to more fair, accurate and uniform approaches for doctors moving from one country to another. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to discover, through a controlled experiment, whether cognitive and non-cognitive assessment would select higher-achieving applicants to medical school than selection by lottery., Methods: We carried out a prospective cohort study to compare 389 medical students who had been admitted by selection and 938 students who had been admitted by weighted lottery, between 2001 and 2004. Main outcome measures were dropout rates, study rate (credits per year) and mean grade per first examination attempt per year. Study rates in the 4 pre-clinical years of medical school were used to categorise students' performance as average or optimal., Results: Pre-admission variables did not differ between the two groups. The main outcome of the selection experiment was that relative risk for dropping out of medical school was 2.6 times lower for selected students than for lottery-admitted controls (95% confidence interval 1.59-4.17). Significant differences between the groups in the percentage of optimally performing students and grade point average for first examination attempts were found only in the 2001 cohort, when results favoured the selected group. The results of the selection process took into account both the assessment procedure involved and the number of students who withdrew voluntarily., Conclusions: This is the first controlled study to show that assessing applicants' non-cognitive and cognitive abilities makes it possible to select students whose dropout rate will be lower than that of students admitted by lottery. The dropout rate in our overall cohort was 2.6 times lower in the selected group.

Background: Before the 1970s, research into the development of clinical competence was mainly focused on general problem-solving abilities. The scope of research changed when Elstein and colleagues discovered that individual ability to solve clinical problems varies considerably across cases. It was concluded that problem solving abilities are highly dependent on domain-specific knowledge rather than on general problem solving skills. Elstein called this phenomenon "case specificity.", Purpose: The finding of content specificity will be contrasted with the existence of a general clinical problem solving ability, and the relationship between preclinical knowledge and a problem solving ability will be investigated., Methods: A correlation matrix was calculated with clerkship final scores from 10 disciplines to examine the magnitude of the interrelations. A confirmatory factor analysis was applied to the corresponding covariances using structural equation modeling to investigate whether scores on finals shared any common variance across clerkships. Finally, two additional models were tested to examine the nature of the relationship between preclinical knowledge and problem solving., Results: Low to moderate correlations across clerkship disciplines were found, supporting the original findings of content specificity. Further investigation showed that in addition to specific knowledge, a general, content-independent ability is needed to perform on these examinations., Conclusions: Clinical competence, as measured in this study, is based on a combination of specific preclinical knowledge and a problem-solving ability. Case specificity fits perfectly well in this interactional perspective on clinical problem solving but does not explain it. The phenomenon "case specificity" is therefore not solely a result of content knowledge, but of level of experience and level of case difficulty.

Purpose: It remains unclear if inflammation itself may induce cancer, if inflammation is a result of tumor growth, or a combination of both exists. The aim of this study was to examine whether C-reactive protein (CRP) levels and CRP gene variations were associated with an altered risk of colorectal, lung, breast, or prostate cancer., Patients and Methods: A total of 7,017 participants age > or = 55 years from the Rotterdam Study were eligible for analyses. Mean follow-up time was 10.2 years. High-sensitivity CRP measurements were performed to identify additional values of 0.2 to 1.0 mg/L compared with standard procedures. Genotypes of the CRP gene were determined with an allelic discrimination assay., Results: High levels (> 3 mg/L) of CRP were associated with an increased risk of incident cancer (hazard ratio, 1.4; 95% CI, 1.1 to 1.7) compared with persons with low levels (< 1 mg/L), even after a potential latent period of 5 years was introduced. Although CRP seems to affect several cancer sites, the association was strongest for lung cancer (hazard ratio, 2.8; 95% CI, 1.6 to 4.9). A CRP single nucleotide polymorphism associated with decreased CRP levels was associated with an increased lung cancer risk of 2.6 (95% CI, 1.6 to 4.4) in homozygous carriers., Conclusion: Baseline CRP levels seem to be a biomarker of chronic inflammation preceding lung cancer, even after subtracting a 5-year latent period. Furthermore, CRP gene variation associated with low CRP blood levels was relatively common in patients with lung cancer. Both chronic inflammation and impaired defense mechanisms resulting in chronic inflammation might explain these results.

Background: Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear., Objectives: This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence., Methods: Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software., Results: Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters., Conclusion: Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.