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Objective To evaluate the effectiveness of an electronic learning (e-learning) programme on the performance of nurses in the recognition of child abuse in a simulated case in the Emergency Department (ED). Design Blinded, randomised controlled trial using pre- and postintervention design. Setting The ED of a University Medical Center in the Netherlands. Participants 38 ED nurses were included, 25 nurses were analysed. Intervention Half of the participants followed a 2-h e-learning programme focused on the recognition of child abuse, the others acted as a control group. Main outcome measurements Individual performance during a case-simulated parent interview to detect child abuse and self-reported self-efficacy for the detection of child abuse. Performance on the simulation was scored by an expert panel using a standardised assessment form which was designed to score quantity and quality of the questions posed by the nurse (minimum score 0; maximum score 114). Results During post-test, nurses in the intervention group performed significantly better during the simulation than the control group, (89 vs 71, 95% CI 2.9 to 33.3), and reported higher self-efficacy (502 vs 447, 95% CI -25.4 to 134.7). Performance in detecting child abuse correlated positively with the self-efficacy score (Spearman correlation 0.387, p value 0.056). Comparing post- and pretest results separately for the intervention and the control group showed a significant increase in performance in the intervention group. Conclusion E-learning improved the performance in case simulations and the self-efficacy of the nurses in the ED in the detection of child abuse. Wider implementation of the e-learning programme to improve the first step in the detection of child abuse is recommended. Trial registration Protocol registration system of clinicaltrials.gov: NCT00844571. [ABSTRACT FROM AUTHOR]

Background: Serious games have the potential to teach complex cognitive skills in an engaging way, at relatively low costs. Their flexibility in use and scalability makes them an attractive learning tool, but more research is needed on the effectiveness of serious games compared to more traditional formats such e-modules. We investigated whether undergraduate medical students developed better knowledge and awareness and were more motivated after learning about patient-safety through a serious game than peers who studied the same topics using an e-module., Methods: Fourth-year medical students were randomly assigned to either a serious game that included video-lectures, biofeedback exercises and patient missions (n = 32) or an e-module, that included text-based lectures on the same topics (n = 34). A third group acted as a historical control-group without extra education (n = 37). After the intervention, which took place during the clinical introduction course, before the start of the first rotation, all students completed a knowledge test, a self-efficacy test and a motivation questionnaire. During the following 10-week clinical rotation they filled out weekly questionnaires on patient-safety awareness and stress., Results: The results showed patient safety knowledge had equally improved in the game group and e-module group compared to controls, who received no extra education. Average learning-time was 3 h for the game and 1 h for the e-module-group. The serious game was evaluated as more engaging; the e-module as more easy to use. During rotations, students in the three groups reported low and similar levels of patient-safety awareness and stress. Students who had treated patients successfully during game missions experienced higher self-efficacy and less stress during their rotation than students who treated patients unsuccessfully., Conclusions: Video-lectures (in a game) and text-based lectures (in an e-module) can be equally effective in developing knowledge on specific topics. Although serious games are strongly engaging for students and stimulate them to study longer, they do not necessarily result in better performance in patient safety issues.

Objective: The purposes of this article are to highlight aspects of tests that increase or decrease their effectiveness and to provide guidelines for constructing high-quality tests in radiology., Conclusion: Many radiologists help construct tests for a variety of purposes. Only well-constructed tests can provide reliable and valuable information about the test taker.

Introduction: Due to the lack of a theoretically embedded overview of the recent literature on medical career decision-making, this study provides an outline of these dynamics. Since differences in educational routes to the medical degree likely affect career choice dynamics, this study focuses on medical career decision-making in educational systems with a Western European curriculum structure., Methods: A systematic search of electronic databases (Medline, Embase) was conducted from January 2008 to November 2014. A panel of seven independent reviewers performed the data extraction, quality assessment and data synthesis using the Bland-Meurer model of medical specialty choice as a reference., Results: Fifty-seven studies met the inclusion criteria for the review. Factors associated with specialty preference or career choice can be classified in five main categories: (1) medical school characteristics (e.g., curriculum structure), (2) student characteristics (e.g., age, personality), (3) student values (e.g., personal preference), (4) career needs to be satisfied (e.g., expected income, status, and work-life balance), and (5) perception of specialty characteristics (e.g., extracurricular or curricular experiences). Especially career needs and perceptions of specialty characteristics are often associated with medical career decision-making., Conclusion: Our results support that medical career decisions are formed by a matching of perceptions of specialty characteristics with personal needs. However, the process of medical career decision-making is not yet fully understood. Besides identifying possible predictors, future research should focus on detecting interrelations between hypothesized predictors and identify the determinants and interrelations at the various stages of the medical career decision-making process.

Feedback is considered important to acquire clinical skills. Research evidence shows that feedback does not always improve learning and its effects may be small. In many studies, a variety of variables involved in feedback provision may mask either one of their effects. E.g., there is reason to believe that the way oral feedback is framed may affect its effect if other variables are held constant. In a randomised controlled trial we investigated the effect of positively and negatively framed feedback messages on satisfaction, self-efficacy, and performance. A single blind randomised controlled between-subject design was used, with framing of the feedback message (positively-negatively) as independent variable and examination of hearing abilities as the task. First year medical students' (n = 59) satisfaction, self-efficacy, and performance were the dependent variables and were measured both directly after the intervention and after a 2 weeks delay. Students in the positively framed feedback condition were significantly more satisfied and showed significantly higher self-efficacy measured directly after the performance. Effect sizes found were large, i.e., partial η (2) = 0.43 and η (2) = 0.32 respectively. They showed a better performance throughout the whole study. Significant performance differences were found both at the initial performance and when measured 2 weeks after the intervention: effects were of medium size, respectively r = -.31 and r = -.32. Over time in both conditions performance and self-efficacy decreased. Framing the feedback message in either a positive or negative manner affects students' satisfaction and self-efficacy directly after the intervention be it that these effects seem to fade out over time. Performance may be enhanced by positive framing, but additional studies need to confirm this. We recommend using a positive frame when giving feedback on clinical skills.

Context: Feedback is considered important in medical education. The literature is not clear about the mechanisms that contribute to its effects, which are often small to moderate and at times contradictory. A variety of variables seem to influence the impact of feedback on learning. The aim of this study was to determine which variables influence the process and outcomes of feedback in settings relevant to medical education., Methods: A myriad of studies on feedback have been conducted. To determine the most researched variables, we limited our review to meta-analyses and literature reviews published in the period from January 1986 to February 2012. According to our protocol, we first identified features of the feedback process that influence its effects and subsequently variables that influence these features. We used a chronological model of the feedback process to categorise all variables found., Results: A systematic search of ERIC, PsycINFO and MEDLINE yielded 1101 publications, which we reduced to 203, rejecting papers on six exclusion criteria. Of these, 46 met the inclusion criteria. In our four-phase model, we identified 33 variables linked to task performance (e.g. task complexity, task nature) and feedback reception (e.g. self-esteem, goal-setting behaviour) by trainees, and to observation (e.g. focus, intensity) and feedback provision (e.g. form, content) by supervisors that influence the subsequent effects of the feedback process. Variables from all phases influence the feedback process and effects, but variables that influence the quality of the observation and rating of the performance dominate the literature. There is a paucity of studies addressing other, seemingly relevant variables., Conclusions: The larger picture of variables that influence the process and outcome of feedback, relevant for medical education, shows many open spaces. We suggest that targeted studies be carried out to expand our knowledge of these important aspects of feedback in medical education., (© 2015 John Wiley & Sons Ltd.)

Rationale and Objectives: In current practice, radiologists interpret digital images, including a substantial amount of volumetric images. We hypothesized that interpretation of a stack of a volumetric data set demands different skills than interpretation of two-dimensional (2D) cross-sectional images. This study aimed to investigate and compare knowledge and skills used for interpretation of volumetric versus 2D images., Materials and Methods: Twenty radiology clerks were asked to think out loud while reading four or five volumetric computed tomography (CT) images in stack mode and four or five 2D CT images. Cases were presented in a digital testing program allowing stack viewing of volumetric data sets and changing views and window settings. Thoughts verbalized by the participants were registered and coded by a framework of knowledge and skills concerning three components: perception, analysis, and synthesis. The components were subdivided into 16 discrete knowledge and skill elements. A within-subject analysis was performed to compare cognitive processes during volumetric image readings versus 2D cross-sectional image readings., Results: Most utterances contained knowledge and skills concerning perception (46%). A smaller part involved synthesis (31%) and analysis (23%). More utterances regarded perception in volumetric image interpretation than in 2D image interpretation (Median 48% vs 35%; z = -3.9; P < .001). Synthesis was less prominent in volumetric than in 2D image interpretation (Median 28% vs 42%; z = -3.9; P < .001). No differences were found in analysis utterances., Conclusions: Cognitive processes in volumetric and 2D cross-sectional image interpretation differ substantially. Volumetric image interpretation draws predominantly on perceptual processes, whereas 2D image interpretation is mainly characterized by synthesis. The results encourage the use of volumetric images for teaching and testing perceptual skills., (Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: Current radiology practice increasingly involves interpretation of volumetric data sets. In contrast, most radiology tests still contain only 2D images. We introduced a new testing tool that allows for stack viewing of volumetric images in our undergraduate radiology program. We hypothesized that tests with volumetric CT-images enhance test quality, in comparison with traditional completely 2D image-based tests, because they might better reflect required skills for clinical practice., Materials and Methods: Two groups of medical students (n=139; n=143), trained with 2D and volumetric CT-images, took a digital radiology test in two versions (A and B), each containing both 2D and volumetric CT-image questions. In a questionnaire, they were asked to comment on the representativeness for clinical practice, difficulty and user-friendliness of the test questions and testing program. Students' test scores and reliabilities, measured with Cronbach's alpha, of 2D and volumetric CT-image tests were compared., Results: Estimated reliabilities (Cronbach's alphas) were higher for volumetric CT-image scores (version A: .51 and version B: .54), than for 2D CT-image scores (version A: .24 and version B: .37). Participants found volumetric CT-image tests more representative of clinical practice, and considered them to be less difficult than volumetric CT-image questions. However, in one version (A), volumetric CT-image scores (M 80.9, SD 14.8) were significantly lower than 2D CT-image scores (M 88.4, SD 10.4) (p<.001). The volumetric CT-image testing program was considered user-friendly., Conclusion: This study shows that volumetric image questions can be successfully integrated in students' radiology testing. Results suggests that the inclusion of volumetric CT-images might improve the quality of radiology tests by positively impacting perceived representativeness for clinical practice and increasing reliability of the test., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Rationale and Objectives: Radiology practice has become increasingly based on volumetric images (VIs), but tests in medical education still mainly involve two-dimensional (2D) images. We created a novel, digital, VI test and hypothesized that scores on this test would better reflect radiological anatomy skills than scores on a traditional 2D image test. To evaluate external validity we correlated VI and 2D image test scores with anatomy cadaver-based test scores., Materials and Methods: In 2012, 246 medical students completed one of two comparable versions (A and B) of a digital radiology test, each containing 20 2D image and 20 VI questions. Thirty-three of these participants also took a human cadaver anatomy test. Mean scores and reliabilities of the 2D image and VI subtests were compared and correlated with human cadaver anatomy test scores. Participants received a questionnaire about perceived representativeness and difficulty of the radiology test., Results: Human cadaver test scores were not correlated with 2D image scores, but significantly correlated with VI scores (r = 0.44, P < .05). Cronbach's α reliability was 0.49 (A) and 0.65 (B) for the 2D image subtests and 0.65 (A) and 0.71 (B) for VI subtests. Mean VI scores (74.4%, standard deviation 2.9) were significantly lower than 2D image scores (83.8%, standard deviation 2.4) in version A (P < .001). VI questions were considered more representative of clinical practice and education than 2D image questions and less difficult (both P < .001)., Conclusions: VI tests show higher reliability, a significant correlation with human cadaver test scores, and are considered more representative for clinical practice than tests with 2D images., (Copyright © 2015 AUR. Published by Elsevier Inc. All rights reserved.)

Competency frameworks are based on what are considered to be the general essential qualities of a doctor. Competencies, being behavioural descriptors, need a strong link to clinical practice to allow trainers to observe and then use them in assessing trainees' performance. The emerging concept of entrustable professional activities (EPAs) may serve as such a link. An EPA is a description of an essential clinical task that frames competencies in the context of clinical practice. A full set of EPAs defines a specialty and constitutes the curriculum of specialty training. After observation of satisfactory performance on an EPA, the resident should be permitted to perform that activity without direct supervision. The terms of this should allow a trainer to provide justification for this decision. This makes graded assumption of responsibilities possible. We describe the potential benefits of working with EPAs in anaesthesiology training and set an agenda for curriculum development and research in this area.

Aim: Pharmacotherapy might be improved if future pharmacists and physicians receive a joint educational programme in pharmacology and pharmacotherapeutics. This study investigated whether there are differences in the pharmacology and pharmacotherapy knowledge and skills of pharmacy and medical students after their undergraduate training. Differences could serve as a starting point from which to develop joint interdisciplinary educational programmes for better prescribing., Methods: In a cross-sectional design, the knowledge and skills of advanced pharmacy and medical students were assessed, using a standardized test with three domains (basic pharmacology knowledge, clinical or applied pharmacology knowledge and pharmacotherapy skills) and eight subdomains (pharmacodynamics, pharmacokinetics, interactions and side-effects, Anatomical Therapeutic Chemical Classification groups, prescribing, prescribing for special groups, drug information, regulations and laws, prescription writing)., Results: Four hundred and fifty-one medical and 151 pharmacy students were included between August 2010 and July 2012. The response rate was 81%. Pharmacy students had better knowledge of basic pharmacology than medical students (77.0% vs. 68.2% correct answers; P < 0.001, δ = 0.88), whereas medical students had better skills than pharmacy students in writing prescriptions (68.6% vs. 50.7%; P < 0.001, δ = 0.57). The two groups of students had similar knowledge of applied pharmacology (73.8% vs. 72.2%, P = 0.124, δ = 0.15)., Conclusions: Pharmacy students have better knowledge of basic pharmacology, but not of the application of pharmacology knowledge, than medical students, whereas medical students are better at writing prescriptions. Professional differences in knowledge and skills therefore might well stem from their undergraduate education. Knowledge of these differences could be harnessed to develop a joint interdisciplinary education for both students and professionals., (© 2014 The British Pharmacological Society.)

Objective: Research on the preference of medical specialty among medical students in the Netherlands and the attractiveness of aspects of the medical profession during the period 2009-2013., Design: Retrospective, descriptive research., Method: Data from medical students in the Netherlands who participated in the computer programme Inventory Medical Professionals Choice (IMBK) were analyzed with respect to their preference of medical specialty and the attractiveness of various aspects of the medical profession. The IMBK programme was available free of charge through the Royal Dutch Medical Association (KNMG) website 'Arts in Spe' (Future Physician) during the period 2009-2013. The content of the IMBK programme was based on the questionnaire from the medical profile book developed by the pharmaceutical company GlaxoSmithKline (GSK)., Results: General practice was the most popular specialty, particularly among female medical students, with interest increasing during the undergraduate medical curriculum. Hardly any students were interested in insurance medicine, occupational medicine and elderly medicine. Direct patient care was the most attractive professional aspect for medical students. Female students were more attracted to direct and prolonged patient contact than their male counterparts. The number of hours students wished to work in future declined during the course of the undergraduate curriculum, and women were more inclined to prefer regular working hours with adequate leisure time than men., Conclusion: During the course of the undergraduate medical curriculum, medical students changed their preference for medical specialty. Major differences exist between male and female students in terms of preference of medical specialty and attractiveness of aspects of the medical profession.

Background: Online formative tests (OFTs) are powerful tools to direct student learning behavior, especially when enriched with specific feedback., Aim: In the present study, we have investigated the effect of OFTs enriched with hyperlinks to microlectures on examination scores., Methods: OFTs, available one week preceding each midterm and the final exams, could be used voluntarily. The use of OFTs was related to scores on midterm and final exams using ANOVA, with prior academic achievement as a covariate., Results: On average, 74% of all students used the online formative tests (OFT+) while preparing for the summative midterm exam. OFT+ students obtained significantly higher grades compared to OFT-students, both without and with correction for previous academic achievement. Two out of three final exam scores did not significantly improve., Conclusion: Students using online formative tests linked to microlectures receive higher grades especially in highly aligned summative tests.

Providing feedback to trainees in clinical settings is considered important for development and acquisition of skill. Despite recommendations how to provide feedback that have appeared in the literature, research shows that its effectiveness is often disappointing. To understand why receiving feedback is more difficult than it appears, this paper views the feedback process through the lens of Self-Determination Theory (SDT). SDT claims that the development and maintenance of intrinsic motivation, associated with effective learning, requires feelings of competence, autonomy and relatedness. These three psychological needs are not likely to be satisfied in most feedback procedures. It explains why feedback is often less effective than one would expect. Suggestions to convey feedback in ways that may preserve the trainee's autonomy are provided.

What Is Already Known About This Subject: The rate of medication errors is high, and these errors can cause adverse drug reactions. Elderly individuals are most vulnerable to adverse drug reactions. One cause of medication errors is the lack of drug knowledge on the part of different health professionals. Medical curricula have changed in recent years, resulting in less education in the basic sciences, such as pharmacology., What This Study Adds: Our study shows that little curricular time is devoted to geriatric pharmacology and that educational programmes in geriatric pharmacology have not been thoroughly evaluated. While interest in pharmacology education has increased recently, this is not the case for geriatric pharmacology education. Education on geriatric pharmacology should have more attention in the curricula of health professionals, given the often complex pharmacotherapy in elderly patients. Educational topics should be related to the known risk factors of medication errors, such as polypharmacy, dose adjustments in organ dysfunction and psychopharmacotherapeutics., Aims: Given the reported high rates of medication errors, especially in elderly patients, we hypothesized that current curricula do not devote enough time to the teaching of geriatric pharmacology. This review explores the quantity and nature of geriatric pharmacology education in undergraduate and postgraduate curricula for health professionals., Methods: Pubmed, Embase and PsycINFO databases were searched (from 1 January 2000 to 11 January 2011), using the terms 'pharmacology' and 'education' in combination. Articles describing content or evaluation of pharmacology education for health professionals were included. Education in general and geriatric pharmacology was compared., Results: Articles on general pharmacology education (252) and geriatric pharmacology education (39) were included. The number of publications on education in general pharmacology, but not geriatric pharmacology, has increased over the last 10 years. Articles on undergraduate and postgraduate education for 12 different health disciplines were identified. A median of 24 h (from 15 min to 4956 h) devoted to pharmacology education and 2 h (1-935 h) devoted to geriatric pharmacology were reported. Of the articles on education in geriatric pharmacology, 61.5% evaluated the teaching provided, mostly student satisfaction with the course. The strength of findings was low. Similar educational interventions were not identified, and evaluation studies were not replicated., Conclusions: Recently, interest in pharmacology education has increased, possibly because of the high rate of medication errors and the recognized importance of evidence-based medical education. Nevertheless, courses on geriatric pharmacology have not been evaluated thoroughly and none can be recommended for use in training programmes. Suggestions for improvements in education in general and geriatric pharmacology are given., (© 2012 The Authors. British Journal of Clinical Pharmacology © 2012 The British Pharmacological Society.)

The script concordance test (SCT) is designed to assess clinical reasoning by adapting the likelihood of a case diagnosis, based on provided new information. In the standard instructions students are asked to exclude alternative diagnoses they have in mind when answering the questions, but it might be more authentic to include these. Fifty-nine final-year medical students completed an SCT. Twenty-nine were asked to take their differential diagnosis into account (adapted instructions). Thirty students were asked not to consider other diagnoses (standard instructions). All participants were asked to indicate for each question whether they were confused answering it with the given instructions ('confusion indication'). Mean score of the test with the adapted instructions was 81.5 (SD 3.8) and of the test with the standard instructions 82.9 (SD 5.0) (p = 0.220). Cronbach's alpha was 0.39 for the adapted instructions and 0.66 for the standard instructions. The mean number of confusion indications was 4.2 (SD 4.4) per student for the adapted instructions and 16.7 (SD 28.5) for the standard instructions (p = 0.139). Our attempt to improve SCTs reliability by modifying the instructions did not lead to a higher alpha; therefore we do not recommend this change in the instructional format.

Context: Despite frequent complaints that biomedical knowledge is quickly forgotten after it has been learned, few investigations of actual long-term retention of basic science knowledge have been conducted in the medical domain., Objectives: Our aim was to illuminate the long-term retention of basic science knowledge, particularly of unrehearsed knowledge., Methods: Using a cross-sectional study design, medical students and doctors in the Netherlands were tested for retention of basic science knowledge. Relationships between retention interval and proportion of correct answers on a knowledge test were investigated., Results: The popular notion that most of basic science knowledge is forgotten shortly after graduation is not supported by our findings. With respect to the full test scores, which reflect a composite of unrehearsed and rehearsed knowledge, performance decreased from approximately 40% correct answers for students still in medical school, to 25-30% correct answers for doctors after many years of practice. When rehearsal during the retention interval is controlled for, it appears that little knowledge is lost for 1.5-2 years after it was last used; from then on, retention is best described by a negatively accelerated (logarithmic) forgetting curve. After ≥ 25 years, retention levels were in the range of 15-20%., Conclusions: Conclusions about the forgetting of unrehearsed knowledge in this study are in line with findings reported in other domains: it proceeds in accordance with the Ebbinghaus curve for meaningful material, except that in our findings the 'downward' part appears to start later than in most other studies. The limitations of the study are discussed and possible ramifications for medical education are proposed., (© Blackwell Publishing Ltd 2011.)

Background: Although the objective in European Union and North American surgical residency programmes is similar-to train competent surgeons-residents' working hours are different. It was hypothesized that practice-ready surgeons with more working hours would perform significantly better than those being educated within shorter working week curricula., Methods: At each test site, 21 practice-ready candidate surgeons were recruited. Twenty qualified Canadian and 19 qualified Dutch surgeons served as examiners. At both sites, three validated outcome instruments assessing multiple aspects of surgical competency were used., Results: No significant differences were found in performance on the integrative and cognitive examination (Comprehensive Integrative Puzzle) or the technical skills test (Objective Structured Assessment of Technical Skill; OSATS). A significant difference in outcome was observed only on the Patient Assessment and Management Examination, which focuses on skills needed to manage patients with complex problems (P < 0.001). A significant interaction was observed between examiner and candidate origins for both task-specific OSATS checklist (P = 0.001) and OSATS global rating scale (P < 0.001) scores., Conclusion: Canadian residents, serving many more working hours, perform equivalently to Dutch residents when assessed on technical skills and cognitive knowledge, but outperformed Dutch residents in skills for patient management. Secondary analyses suggested that cultural differences influence the assessment process significantly., ((c) 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Objectives: Recently, many medical schools' curricula have been revised so that they represent vertically integrated (VI) curricula. Important changes include: the provision of earlier clinical experience; longer clerkships, and the fostering of increasing levels of responsibility. One of the aims of vertical integration is to facilitate the transition to postgraduate training. The purpose of the present study is to determine whether a VI curriculum at medical school affects the transition to postgraduate training in a positive way., Methods: We carried out a questionnaire study among graduates of six medical schools in the Netherlands, who had followed either a VI or a non-VI curriculum. Items in the questionnaire focused on preparedness for work and postgraduate training, the time and number of applications required to be admitted to residency, and the process of making career choices., Results: In comparison with those who have followed non-VI programmes, graduates of VI curricula appear to make definitive career choices earlier, need less time and fewer applications to obtain residency positions and feel more prepared for work and postgraduate training., Conclusions: The curriculum at medical school affects the transition to postgraduate training. Additional research is required to determine which components of the curriculum cause this effect and to specify under which conditions this effect occurs.

Context: At present, competency-based, outcome-focused training is gradually replacing more traditional master-apprentice teaching in postgraduate training. This change requires a different approach to the assessment of clinical competence, especially given the decisions that must be made about the level of independence allowed to trainees., Methods: This study was set within postgraduate obstetrics and gynaecology training in the Netherlands. We carried out seven focus group discussions, four with postgraduate trainees from four training programmes and three with supervisors from three training programmes. During these discussions, we explored current opinions of supervisors and trainees about how to determine when a trainee is competent to perform a clinical procedure and the role of formal assessment in this process., Results: When the focus group recordings were transcribed, coded and discussed, two higher-order themes emerged: factors that determine the level of competence of a trainee in a clinical procedure, and factors that determine the level of independence granted to a trainee or acceptable to a trainee., Conclusions: From our study, it is evident that both determining the level of competence of a trainee for a certain professional activity and making decisions about the degree of independence entrusted to a trainee are complex, multi-factorial processes, which are not always transparent. Furthermore, competence achieved in a certain clinical procedure does not automatically translate into more independent practice. We discuss the implications of our findings for the assessment of clinical competence and provide suggestions for a transparent assessment structure with explicit attention to progressive independence.

Aims: Self-efficacy may predict performance following life-support training but may be negatively influenced by experiences during training. To investigate both this and the use of self-efficacy in self-assessment we investigated the relationship between self-efficacy and measured performance during a simulated resuscitation, and the effect of death of a simulated patient on self-efficacy., Materials and Methods: Consultant and trainee paediatricians and anaesthesiologists scored their self-efficacy for paediatric resuscitation skills before taking an unannounced simulated resuscitation test and objective structured clinical examination (OSCE)-tests of chest compressions and bag- and mask-ventilation. Performance in the simulation was scored by three independent expert observers and the OSCE's using a modified Berden and ventilation penalty scores., Results: Self-efficacy for the relevant skill was significantly higher in doctors choosing to give chest compressions, to intubate or insert an intraosseous device and in those who decided to intubate early. Self-efficacy correlated moderately with the quality of global performance on the simulation but not with the OSCE scores, nor was quality of individual skills during the simulation related to self-efficacy. Self-efficacy was higher in doctors who had taken the Advanced Paediatric Life Support (APLS)-course. Death of the simulated patient had a negative effect on self-efficacy., Conclusion: Self-efficacy seems to be predictive of certain actions during a simulated resuscitation but does not correlate with quality of performance of resuscitation skills. Self-efficacy might therefore be useful as a predictor of the application of learning, but cannot be recommended for self-assessment. There is evidence to support the unwritten rule during simulation training the patient should not be allowed to die.

Background: Clinical experience is considered to affect medical students' career preferences. It is not known whether the sequence of the clinical rotations influences these preferences., Aim: To explore whether the first clinical clerkship has more impact on career preference than the second by examining the association between the first clinical clerkship and the choice of an elective sixth-year internship., Method: University Medical Center Utrecht students are assigned to either a surgical or a medical ward for the first third-year clerkship and to the other ward for the second clerkship. In a retrospective cohort study, internship data of 488 sixth-year students were related to their first clerkship 3 years earlier., Results: For the group as a whole, no association was found between third-year clerkship and sixth-year internship. However, male students who had been assigned to surgery first more often chose a surgical internship than those who had been assigned to medical clerkship first and vice versa (p < 0.02). Within the female subgroup, no association was found., Conclusion: A positive association between the nature of the clerkship and the sixth-year internship preference among male students suggest that the first clinical experience can affect later specialty preference.

Objective: To investigate whether the transition from a conventional, discipline-based curriculum to a problem-orientated, integrated curriculum at the University Medical Center Utrecht, the Netherlands, has resulted in students having less knowledge of the basic medical sciences., Design: Comparative., Method: The difference in the amount of basic science between the curricula was quantitatively assessed. 37 final-year students in each curriculum volunteered to complete a test specifically designed to measure knowledge of the basic sciences, a few weeks before their graduation., Results: The transition from the old to the new curriculum resulted in a decline of almost half in the amount of time dedicated to the basic sciences, from 84 to 48 'fulltime week equivalents'. Students in the old curriculum performed significantly better on the test than students in the new curriculum, with 43.2% (SD: 9.56) correct answers versus 35.8% (SD: 8.19) correct answers respectively, which amounted to an effect size of 0.828 (Cohen-d). Yet, on the pathophysiology/pathology subscale, students in each curriculum showed similar performance: 36.1% (SD: 11.55) correct answers for students in the old curriculum, versus 37.2% (SD: 11.66) correct answers for students in the new curriculum., Conclusion: Students in the old curriculum had overall significantly more knowledge of the basic sciences than students in the new curriculum, except for pathophysiology/pathology, though the time devoted to this discipline in the new curriculum had also decreased considerably.

Context: Ber's Comprehensive Integrative Puzzle aims to assess analytical clinical thinking in medical students. We developed a paediatric version, the MATCH test, in which we added two irrelevant options to each question in order to reduce guessing behaviour. We tested its construct validity and studied the development of integrative skills over time., Methods: We administered a test (MATCH 1) to subjects from two universities, both with a 6-year medical training course. Subjects included 30 students from university 1 who had completed a paediatric clerkship in Year 4, 23 students from university 2 who had completed a paediatric clerkship in Year 5, 13 students from both universities who had completed an advanced paediatric clerkship in Year 6, 28 paediatric residents and 17 paediatricians. We repeated this procedure using a second test with different domains in a new, comparable group of subjects (MATCH 2)., Results: Mean MATCH 1 scores for the respective groups were: Year 4 students: 61.2% (standard deviation [SD] 1.3); Year 5 students: 71.3% (SD 1.6); Year 6 students: 76.2% (SD 1.5); paediatric residents: 88.5% (SD 0.7), and paediatricians: 92.2% (SD 1.1) (one-way ANOVA F = 104.00, P < 0.0001). Students of both universities had comparable scores. MATCH 1 and 2 scores were comparable. Cronbach's alpha-values in MATCH 1 and 2 were 0.92 and 0.91, respectively, for all subjects, and 0.82 and 0.87, respectively, for all students., Conclusions: Analytical clinical thinking develops over time, independently of the factual content of the course. This implies that shortened medical training programmes could produce less skilled graduates.

Context: Self-efficacy is an important factor in many areas of medical education, including self-assessment and self-directed learning, but has been little studied in resuscitation training, possibly because of the lack of a simple measurement instrument., Objective: We aimed to assess the validity of a visual analogue scale (VAS) linked to a single question as an instrument to measure self-efficacy with respect to resuscitation skills by comparing the VAS with a questionnaire and using known-groups comparisons., Methods: We developed questionnaires to measure self-efficacy for a number of resuscitation tasks and for computer skills. These were compared with VASs linked to a single question per task, using a multi-trait, multi-method matrix. We also used known-groups comparisons of self-efficacy in specific professional groups., Results: There was good correlation between the questionnaires and the VASs for self-efficacy for specific resuscitation tasks. There was a less clear correlation for self-efficacy for paediatric resuscitation overall. There was no correlation between self-efficacy for resuscitation and computer tasks. In specific professional groups, measured self-efficacy accorded with theoretical predictions., Conclusions: A VAS linked to a single question appears to be a valid method of measuring self-efficacy with respect to specific well defined resuscitation tasks, but should be used with caution for multi-faceted tasks.

Objective: Feedback is important in clinical education. However, the medical education literature provides no consensual definition of feedback. The aim of this study is to propose a consensual, research-based, operational definition of feedback in clinical education. An operational definition is needed for educational practice and teacher training, and for research into the effectiveness of different types of feedback., Methods: A literature search about definitions of feedback was performed in general sources, meta-analyses and literature reviews in the social sciences and other fields. Feedback definitions given from 1995 to 2006 in the medical education literature are also reviewed., Results: Three underlying concepts were found, defining feedback as 'information'; as 'reaction', including information, and as a 'cycle', including both information and reaction. In most medical education and social science literature, feedback is usually conceptualised as information only. Comparison of feedback definitions in medical education reveals at least 9 different features. The following operational definition is proposed. Feedback is: 'Specific information about the comparison between a trainee's observed performance and a standard, given with the intent to improve the trainee's performance.', Conclusions: Different conceptual representations and the use of different key features might be a cause for inconsistent definitions of feedback. The characteristics, strengths and weaknesses of this research-based operational definition are discussed.

Background: Medical students develop interest in a specialty career during medical school based on knowledge and clinical experience of different specialties. How valid this knowledge is and how this knowledge relates to the development of preference for a specialty is not known. We studied their "subjective" knowledge of a specialty (students' reported knowledge) with "objective" knowledge of it (students actual knowledge as compared to reports of specialists) and their preference for this specialty at different stages of education, and used youth health care as a case study., Methods: Students from all years in two medical schools (N = 2928) were asked to complete a written questionnaire including (a) a statement of their knowledge of youth health care (YHC) ("subjective knowledge"), (b) their preference for a YHC career and (c) a list of 47 characteristics of medical practice with the request to rate their applicability to YHC. A second questionnaire containing the same 47 characteristics were presented to 20 practicing youth health physicians with the request to rate the applicability to their own profession. This profile was compared to the profiles generated by individual student's answers, resulting in what we called "objective knowledge.", Results: Correlation studies showed that "subjective knowledge" was not related to "objective knowledge" of the YHC profession (r = 0.05), but significantly to career preference for this field (r = 0.29, P < 0.01). Preference for a YHC career hardly correlated with objective knowledge about this profession (r = 0.11, P < 0.05). Students with YHC clerkships showed no better "objective knowledge" about the profession than students without such experience., Conclusion: Career preference aren't always related to prior experiences, or to actual knowledge of the area. This study shows how careful we should be to trust students' opinions and preferences about specialties; they probably need much guidance in career choice.

Background: This study is the longitudinal sequel to a survey published by Custers and Ten Cate in December 2002 in which advanced medical students' attitudes towards the basic sciences were investigated. Students were enrolled in either a conventional or an innovative curriculum., Aims and Methods: The aim of the present study was to assess longitudinal development of students' attitudes by recording beginning and advanced clerks responses to nine disagree-agree statements concerning the basic sciences., Results: In general, most students in either curriculum acknowledge the importance of biomedical knowledge. Students in the conventional curriculum appear to assign a slightly more important role to the basic sciences than students in the innovative curriculum, and this difference is maintained over the clinical years. Surprisingly, advanced clerks in either curriculum are more likely than beginning clerks to support the view that many basic science facts should be learned before application in a clinical context., Conclusions: These findings suggest that students during their clerkships might experience regret having not paid more attention to factual basic science knowledge in their preclinical years. Finally, students in the innovative curriculum hold more favourable opinions about the way the basic sciences are taught in their curriculum.

Context: In 2003 the Dutch Central College of Medical Specialties presented guidelines for the modernisation of all medical specialty training programmes in the Netherlands. These guidelines are based to a large extent on the CanMEDS (Canadian Medical Education Directives for Specialists) 2000 model, which defines 7 roles for medical specialists. This model was adjusted to the Dutch situation. The roles were converted to 7 fields of competency: Medical Performance; Communication; Collaboration; Knowledge and Science; Community Performance; Management, and Professionalism., Objective: As changes in postgraduate training will probably be most effective if future trainees recognise their value, we set out to determine how senior medical students rated these fields of competency in terms of their importance., Methods: We carried out a study at University Medical Centre (UMC) Utrecht, the Netherlands, in which 80 Year 6 medical students answered a questionnaire in which they rated the importance of each of 28 key competencies within the 7 competency fields., Results: Although all key competencies were regarded as important (averages > or = 3.8), Professionalism and Communication scored highest on the student ratings. Management was assessed as least important., Conclusions: It is interesting that medical students acknowledged the importance of competencies other than those involving medical expertise and performance. It confirms the opinion that educating doctors is currently viewed as much more than providing theoretical and clinical knowledge and skills. The CanMEDS framework is appreciated by Dutch medical students. The fact that all competencies are seen as important adds to their face validity and therefore to their usefulness as a basis for postgraduate training.

Background: Perceived self-efficacy is a predictor of behaviour and therefore an important dimension of resuscitation training which may have consequences for patient care. The Advanced Paediatric Life Support (APLS) course makes use of techniques which would be expected to increase self-efficacy. We examined the effect of this course on perceived self-efficacy in respect of resuscitation skills and on the use of these skills., Design: A prospective descriptive study using a questionnaire., Methods: Questionnaires were sent to all doctor candidates following the course in the Netherlands over a period of 15 months and to a matched control group. Perceived self-efficacy in respect of paediatric resuscitation as a whole and six of its component skills was measured on a visual analogue scale. Questionnaires were sent out before the course and 3 and 6 months afterwards., Findings: The candidate and control groups were not significantly different in terms of sex, specialty, grade or experience with children. Perceived self-efficacy increased significantly (p<0.01) in candidates following the course for all skills and remained increased for at least 6 months. There was no significant change in perceived self-efficacy in the control group. There was no change in the use of skills or in the number of critically ill children seen, in either group., Conclusions: The APLS course does have an important effect on perceived self-efficacy but this is not related to an increase in the frequency of use of the skills learned on the course, partly because the opportunity for increased use is lacking. Further work is needed to determine whether the quality of those skills is improved by the course.

The aim of the present study was to investigate whether basic scientists and physicians agree on the required depth of biomedical knowledge of medical students at graduation. A selection of basic science and clinical teachers rated the relevance of biomedical topics for students at graduation, illustrated by 80 example items. The items were derived from ten organ systems and designed at four levels: clinical, organ, cellular and molecular. Respondents were asked to identify for each item to what extent recently graduated medical students should have knowledge about it. In addition, they were asked to indicate whether the content of the item should be included in the medical curriculum. Analysis showed that basic scientists and physicians do not diverge at the clinical level. At the organ, cellular and molecular levels however, basic scientists judge that medical students should have more active knowledge. As expected, basic scientists also indicate that more deep level content should be included. Explanations for this phenomenon will be discussed.

Background: There is increasing interest in the role of context in medical education, with the conjecture that learning in a clinical context may be helpful for later recall of knowledge. Although this may be true in a general sense, at a closer look it appears that the notion of context is not well substantiated in the medical education literature and that the concept is not clearly defined. Effects of context on learning appear to depend on type of learning task, the relationship or interaction between the context and the learning material, and motivational features of the context. Context is often implicitly regarded as a uniform concept but conceptual analysis shows that a distinction can be made in several dimensions., Results: In this paper, we identify 3 different dimensions of context: a physical dimension, representing the environmental characteristics; a semantic dimension, reflecting how well the context contributes to the learning task, and a commitment dimension, representing the amount of commitment (in terms of motivation and responsibility) that is generated by the context. On these dimensions, context can be ordered from reduced (providing few cues, little meaning, little commitment) to enriched (many cues, much meaning, high commitment)., Conclusion: This model can serve a dual purpose: first, to disentangle several aspects of educational contexts (e.g. as high in meaning but low in commitment), and second, to provide a theoretical framework to generate research on the influence of different contexts in education on students' learning.

Background: Curriculum constructors and teachers must decide on the content and level of objectives and materials included in the medical curriculum. At University Medical Centre Utrecht it was decided to test relatively detailed knowledge at a regular level in study blocks and to design a progress test aimed at the medical core knowledge that every graduating doctor should possess. This study was conducted to validate the level of knowledge tested in this progress test., Aim: We designed a questionnaire to investigate whether postgraduate trainees and experienced specialists agree with item writers on what is required core knowledge., Methods: Postgraduates and specialists received a questionnaire with 80 items designed to test core knowledge. Respondents were asked to indicate to what extent the items actually represented the core knowledge required of a recently graduated medical student., Results: Of the clinical questions, 82.4% were judged to reflect core knowledge, whereas only 42.4% of the basic science questions were judged to reflect core knowledge. There was a strikingly high correlation on the mean judgements per item of postgraduate trainees versus medical specialists (r = 0.975)., Conclusion: Many items, written to reflect core knowledge, appear to be judged by postgraduates and clinicians as pertaining to non-core knowledge. Postgraduate trainees appear to be as capable as experienced specialists of making judgements regarding core knowledge. Fewer basic science items are regarded as core knowledge than clinical items. This may suggest that, specifically, basic science teachers do not agree with physicians on what is to be considered medical core knowledge for graduating doctors.

Recently the authors developed and implemented a new approach to clinical reasoning education called clinical reasoning theater (CRT). The purpose of CRT is to demonstrate the process of clinical reasoning to students through the conversation of a doctor with his or her patient. With students as the audience, the doctor's clinical reasoning skills are modeled in CRT when he or she thinks aloud during conversations with the patient, which makes clear why he or she asks particular questions. In CRT the interaction between doctor and patient is analyzed in such a way that the repeated cycles of questions and answers are revealed to the students. CRT's format and the activities of the three "actors,"(the doctor, the patient, and the audience of students) are described. Two "acts" are repeatedly performed. The first act (the communication between the doctor and the patient) deals with the history taking, physical examination, etc. The second act, the time-out period, is the most important component of CRT. In this act, the doctor explains his or her reflections and discusses suggestions from the audience for additional questions. The preliminary results of students' evaluations of the relevance of CRT reveal that they appreciate CRT. Further, the CRT format offers instructors with previous experience as lecturers only sufficient tools to apply the new approach successfully.

Purpose: Learning-in-context is a much-discussed topic in medical education. Information is said to be better recalled when the learning environment resembles the later retrieval environment. Godden and Baddeley (1975) showed that divers recalled words better when the recall condition matched the original learning environment, i.e. underwater or on land. Though it is unclear whether the findings can be generalized for medical education, medical educators regularly refer to them. We replicated the Godden and Baddeley study in ecologically more valid conditions for medical education and extended it with meaningful subject matter (namely, a patient case description)., Method: Sixty-three clerks were randomized over four conditions, contrasting a clinical (bedside) with an educational (classroom) environment as both learning and recall conditions. Students were asked to recall a list of words and a patient case in the same environment or in the opposite environment as where they learned it., Results: We failed to find a significant same-context advantage for free recall of the list of words and the patient case propositions. However, there does appear to be a slight tendency towards better recall of the case description when learning took place in the clinical environment., Discussion: In medical education, the context, if conceived as physical surroundings, does not seem to contribute to a same-context advantage. One should be cautious in generalizing the findings of Godden and Baddeley. However, different forms of 'context' other than the physical one used in the Godden and Baddeley study may well enhance learning effects in medical education.