Anna E. Oswald

Problem-based learning in pre-clinical medical education: 22 years of outcome research.

Purpose: To conduct a systematic review of problem-based learning (PBL) in undergraduate, pre-clinical medical education. Methods: A research librarian developed comprehensive search strategies for MEDLINE, PSYCINFO, and ERIC (1985–2007). Two reviewers independently screened search results and applied inclusion criteria. Studies were included if they had a comparison group and reported primary data for evaluative outcomes. One reviewer extracted data and a second reviewer checked data for accuracy. Two reviewers independently assessed methodological quality. Quantitative synthesis was not performed due to heterogeneity. A qualitative review with detailed evidence tables is provided. Results: Thirty unique studies were included. Knowledge acquisition measured by exam scores was the most frequent outcome reported; 12 of 15 studies found no significant differences. Individual studies demonstrated either improved clerkship (N = 3) or residency (N = 1) performance, or benefits on some clinical competencies during internships for PBL (N = 1). Three of four studies found some benefits for PBL when evaluating diagnostic accuracy. Three studies found few differences of clinical (or practical) importance on the impact of PBL on practicing physicians. Conclusions: Twenty-two years of research shows that PBL does not impact knowledge acquisition; evidence for other outcomes does not provide unequivocal support for enhanced learning. Work is needed to determine the most appropriate outcome measures to capture and quantify the effects of PBL. General conclusions are limited by methodological weaknesses and heterogeneity across studies. The critical appraisal of previous studies, conducted as part of this review, provides direction for future research in this area.

The effects of audience response systems on learning outcomes in health professions education. A BEME systematic review: BEME Guide No. 21

Background: Audience response systems (ARS) represent one approach to make classroom learning more active. Although ARS may have pedagogical value, their impact is still unclear. This systematic review aims to examine the effect of ARS on learning outcomes in health professions education. Methods: After a comprehensive literature search, two reviewers completed title screening, full-text review and quality assessment of comparative studies in health professions education. Qualitative synthesis and meta-analysis of immediate and longer term knowledge scores were conducted. Results: Twenty-one of 1013 titles were included. Most studies evaluated ARS in lectures (20 studies) and in undergraduates (14 studies). Fourteen studies reported statistically significant improvement in knowledge scores with ARS. Meta-analysis showed greater differences with non-randomised study design. Qualitative synthesis showed greater differences with non-interactive teaching comparators and in postgraduates. Six of 21 studies reported student reaction; 5 favoured ARS while 1 had mixed results. Conclusion: This review provides some evidence to suggest the effectiveness of ARS in improving learning outcomes. These findings are more striking when ARS teaching is compared to non-interactive sessions and when non-randomised study designs are used. This review highlights the importance of having high quality studies with balanced comparators available to those making curricular decisions.

Teaching musculoskeletal clinical skills to medical trainees and physicians: A Best Evidence in Medical Education systematic review of strategies and their effectiveness: BEME Guide No. 18

Background: Musculoskeletal (MSK) complaints make up 12–20% of primary health visits and are a source of significant expenditures and morbidity. Despite this, MSK examination is an area of weakness among practising physicians. Several studies have highlighted the need for increased MSK physical exam teaching. However, increased teaching time alone does not guarantee improvement in these skills. Thus, we aimed to identify interventions that are effective in promoting transfer of MSK clinical skills. Methods: The review protocol was approved by the Best Evidence in Medical Education (BEME) organization. A comprehensive search was conducted and systematic review methods were applied. Data were not pooled statistically due to heterogeneity. Results: About 5089 titles were screened; 24 studies were included. Eighteen of 24 studies focused on undergraduate medical education. Five of nine studies favoured patient educator. Five of six studies favoured interactive small groups, two of four studies favoured computer-assisted learning, and two of two studies favoured peer learning. Individual studies demonstrated effectiveness of reminder sheets and Gait Arms Legs Spine teaching, respectively. Conclusions: This study supports the use of different instructional methods that engage learners and provide meaningful learning contexts. The majority of the studies support patient educators and interactive small group teaching.

The current state of musculoskeletal clinical skills teaching for preclerkship medical students.

Objective Musculoskeletal (MSK) complaints have high prevalence in primary care practice (12%–20% of visits), yet many trainees and physicians identify themselves as weak in MSK physical examination (PE) skills. As recruitment to MSK specialties lags behind retirement rates, there is a short-age of physicians able to effectively teach this subject. We investigated current practices of Canadian undergraduate medical programs regarding the nature, amount, and source of preclerkship MSK PE clinical skills teaching; and documented the frequency and extent that Patient Partners® in Arthritis (PP®IA) are used in this educational setting. Methods A 2-page self-administered electronic questionnaire combining open- and close-ended questions was developed and piloted. It was distributed by e-mail to all Canadian undergraduate associate-deans and to 16/17 undergraduate MSK course organizers. Results Supervised practice in small groups and the PP®IA are the most prevalent teaching methods. Objective structured clinical examinations are the most prevalent evaluation methods. The average number of hours devoted to teaching these skills is very small compared to the prevalence of MSK complaints in the population. Canadian schools’ preclerkship MSK PE clinical skills teaching is heavily dependent on the contributions of non-MSK specialists. Conclusion The weak link in the Canadian MSK PE educational cycle appears to be the amount of time available for students’ deliberate practice with expert feedback. There is a need for methods to evaluate and further develop MSK PE teaching by non-MSK specialists. This and increased use of PP®IA at the preclerkship level may provide students more time for practice with feedback.

The impact of trained patient educators on musculoskeletal clinical skills attainment in pre-clerkship medical students

BackgroundDespite the high burden of musculoskeletal (MSK) diseases, few generalists are comfortable teaching MSK physical examination (PE) skills. Patient Partners® in Arthritis (PP®IA) is a standardized patient educator program that could potentially supplement current MSK PE teaching. This study aims to determine if differences exist in MSK PE skills between non-MSK specialist physician and PP®IA taught students.MethodsPre-clerkship medical students attended 2-hour small group MSK PE teaching by either non-MSK specialist physician tutors or by PP®IA. All students underwent an MSK OSCE and completed retrospective pre-post questionnaires regarding comfort with MSK PE and interest in MSK.Results83 students completed the OSCE (42 PP®IA, 41 physician taught) and 82 completed the questionnaire (42 PP®IA, 40 physician taught). There were no significant differences between groups in OSCE scores. For all questionnaire items, post-session ratings were significantly higher than pre-session ratings for both groups. In exploratory analysis PP®IA students showed significantly greater improvement in 12 of 22 questions including three of five patient-centred learning questions.ConclusionsPP®IA MSK PE teaching is as good as non-MSK specialist physician tutor teaching when measured by a five station OSCE and provide an excellent complementary resource to address current deficits in MSK PE teaching.

Musculoskeletal examination teaching by patients versus physicians: How are they different? Neither better nor worse, but complementary

Background: Musculoskeletal (MSK) complaints comprise 12–20% of primary healthcare; however, practicing physicians’ MSK physical examination (PE) skills are weak. Further, there is a shortage of specialists able to effectively teach this subject. Previous evaluations of patient educators have yielded mixed results. Aims: The aim of this study is to document how teaching by patient educators and physician tutors in MSK PE skills differs. Methods: A qualitative researcher observed, video-recorded, and took notes during preclerkship MSK PE teaching sessions given by patient educators or physician tutors. The researcher identified themes which were evaluated by collective case study methods. Results: Two patient educator and four physician groups were evaluated. The patient educators were more consistent regarding content and style than the physicians. There appeared to be a continuum in teaching organization from patient educator to novice physician tutors to experienced physician tutors. The patient educators consistently covered all major joints (physicians did not); physicians were more likely to request verbalization of actions, relate findings to history, receive questions, and use opportunistic teaching moments. Conclusions: Understanding preclerkship MSK teaching by patient educators compared to physician tutors is necessary for appropriate targeting of the existing Patient Partners® in Arthritis patient educator program and to guide the development of future MSK teaching initiatives.

Exertional paraspinal muscle rhabdomyolysis and compartment syndrome: a cause of back pain not to be missed

Exertional compartment syndrome has been described and implicated in pain syndromes involving several fascial compartments. This entity is classically characterized in the legs, feet and forearms of athletes. We describe a case of acute, severe exertional compartment syndrome of the paraspinal muscles in a young and healthy male ultimately resulting in significant rhabdomyolysis and acute kidney injury. The rarity of the syndrome has prevented the establishment of specific guidelines for management; therefore, we will discuss this case in the context of similar previously reported cases, contrasting the various treatment approaches and outcomes described in previous reports. This discussion outlines a syndrome not commonly considered in the differential diagnosis of back pain.

Group of seven: eMERGing from the wilderness together

Context and setting This grassroots initiative was developed by a group of faculty staff at a large research-intensive North American medical school. Although this institution had a well-established infrastructure for research in basic and clinical sciences, there was little institutional support for scholarly activities in medical education. Why the idea was necessary A number of junior to mid-career faculty members with scholarly interests in medical education felt that their enthusiasm and academic productivity were suffering from a lack of mentorship and sense of shared community. Many reported that difficulties in balancing academic and clinical roles were contributing to stalled research initiatives and incomplete advanced degrees in education. What was done The idea for a peer-mentoring group evolved from several chance conversations at national medical education meetings. In May 2008, through informal means (connections through individual departments, committees and word of mouth), a group of seven individuals with specific interests in pursuing educational scholarship met and formed the Medical Education Research Group (MERG). The terms of reference (membership, scheduling and expectations of members) were developed and the group has met monthly since September 2008. At each meeting, members briefly report on their activities related to educational scholarship. There is then an opportunity for members to solicit feedback and advice from the group on manuscripts, research proposals, grant applications, etc. Finally, each member sets several goals for the upcoming month, which are recorded and circulated prior to the next meeting. Evaluation of results and impact After 18 months, an online survey was distributed to all members to determine whether MERG was having a positive impact. Most members reported feeling more motivated to initiate, present and publish academic work in education as a result of their participation in MERG. Over the first 18 months, its seven members had completed four Masters degrees in medical education, developed 14 research proposals, submitted six successful grant applications, presented 33 abstracts at national or international meetings, and won eight teaching awards. Three collaborative research projects were underway. All members felt that MERG provided peer support and advice and encouraged educational scholarship. Narrative comments echoed the positive impact the group has had on attitude and productivity. Members’ comments included: ‘This group has kept my interest and enthusiasm for medical education alive;’ ‘[I have] tried projects I might not have done otherwise;’ ‘[I am] reminded of the importance of doing something scholarly,’ and ‘I feel connected to a greater community.’ Members felt that elements essential to MERG’s success included a small, closed and committed membership, mutually agreed terms of reference and regular goal setting. They felt that their experience would be further enhanced by having occasional ‘themed’ meetings at which discussions would focus around a particular topic and an expert guest would be invited to attend as a consultant. On a faculty-wide level, MERG has also had a positive impact. Members of this group have initiated an open medical education journal club with the purpose of building a larger community of individuals with an interest in the medical education literature, and plan to form additional peer-mentoring groups to provide more faculty members with opportunities for similar support.

Building capacity for education research among clinical educators in the health professions: A BEME (Best Evidence Medical Education) Systematic Review of the outcomes of interventions: BEME Guide No. 34.

Abstract Background/purpose: There is a growing desire for health professions educators to generate high-quality education research; yet, few of them encounter the training to do so. In response, health professions faculties have increasingly been devoting resources to provide members with the skills necessary for education research. The form and impact of these efforts have not been reviewed, though such a synthesis could be useful for practice. The objectives of this systematic review were to (1) identify interventions aimed at building capacity for education research among health professions clinical educators and (2) review the outcomes of these interventions. Methodology: We developed a systematic review protocol based on our pilot scoping search. This protocol underwent peer review and was prospectively registered with the Best Evidence Medical Education Collaboration. Based on this protocol, we conducted a comprehensive search of health professions’ databases and related grey literature. Systematic methods were applied: two independent reviewers completed title screening and full text review for inclusion, data extraction, and methodological quality assessment. Studies were included if they reported outcomes for interventions designed to increase capacity for health professions clinical educators to conduct education research. We conducted a qualitative synthesis of the evidence which included detailed reporting of intervention characteristics and outcomes. Results: Our search returned 14, 149 results, 241 of which were retained after title and abstract screening, and 30 of which met inclusion criteria after full text review. Seven groups of interventions were identified, the most frequent being teaching scholars programs (n = 10), health professions education fellowships (n = 3) or master’s programs (n = 4). The most commonly measured outcome was change related to enhanced scholarly outputs (grants, papers, abstracts, and presentations) post-intervention. Unfortunately, most of the included studies lacked detailed description of the intervention and were of low to moderate quality with post-test only design. Discussion/conclusions: This review demonstrates that various interventions can have a positive impact on the ability of health professions clinical educators to conduct education research. We note several key elements of the interventions including: (1) protected time, (2) mentorship and/or collaboration, (3) departmental and institutional commitment and leadership, and (4) financial support. Through our analysis we describe the complexities around evaluating clinical educators’ health professions research activities and the interventions used to promote education research. While improved study quality would allow more detailed understanding and evaluation of these key features, we are able to provide recommendations for potential strategies for improving participation in and quality of health professions education research based on this analysis.

At the precipice: a prospective exploration of medical students’ expectations of the pre-clerkship to clerkship transition

Medical learners face many challenging transitions. We prospectively explored students’ perceptions of their upcoming transition to clerkship and their future professional selves. In 2013, 160/165 end-of-second-year medical students wrote narrative reflections and 79/165 completed a questionnaire on their perceptions of their upcoming transition to clerkship. Narratives were separately analyzed by four authors and then discussed to identify a final thematic framework using parsimonious category construction. We identified two overarching themes: (1) “Looking back”: experiences which had helped students feel prepared for clerkship with subthemes focused on of patient care, shadowing, classroom teaching and the pre-clerkship years as foundational knowledge, (2) “Looking forward”: anticipating the clerkship experience and the journey of becoming a physician with subthemes focused on death and dying, hierarchy, work-life balance, interactions with patients, concerns about competency and career choice. Questionnaire data revealed incongruities around expectations of minimal exposure to death and dying, little need for independent study and limited direct patient responsibility. We confirmed that internal transformations are happening in contemplative time even before clerkship. By prospectively exploring pre-clerkship students’ perceptions of the transition to clerkship training we identified expectations and misconceptions that could be addressed with future curricular interventions. While students are aware of and anticipating their learning needs it is not as clear that they realise how much their future learning will depend on their own inner resources. We suggest that more attention be paid to professional identity formation and the development of the physician as a person during these critical transitions.