Diana F Wood

ABC of learning and teaching in medicine: Problem based learning

Problem based learning is used in many medical schools in the United Kingdom and worldwide. This article describes this method of learning and teaching in small groups and explains why it has had an important impact on medical education.

Support for students with academic difficulties

Context  The human and financial costs of academic failure amongst medical students are extremely high. Often, remedial support is infrequently available or is available only for students failing their final examinations. We describe the design, implementation and preliminary evaluation of a remedial programme (RP) for students who experience academic difficulties.

The effect of an extended hospital induction on perceived confidence and assessed clinical skills of newly qualified pre‐registration house officers

Background  Recent studies raise concerns over the preparedness of newly qualified doctors for the role of the pre‐registration house officer (PRHO). This study aimed to assess self‐perception of preparedness, objective assessment of core clinical skills and the effect of an extended clinical induction programme prior to commencing full duties.

New approaches to learning clinical skills.

could be challenging. Moreover, it is not clear what portion of the preceptor’s interpersonal characteristics that create the resident’s perception of psychological size and distance represents malleable behaviours. If these characteristics mostly consist of stable and relatively impenetrable personality traits, they might require extensive intervention, a fact that possibly explains the roots of the adage that great teachers are born, not made . 3 It is unclear how psychological size and distance could be used to make a resident)preceptor pairing that would be perceived as a good match as they mainly describe a relationship that is already in existence. It may or may not represent the ideal relationship for either party. One could reframe the question by asking participants to describe their optimum size and distance relationship and use this to make a match. However, what if a resident’s optimum relationship requires the preceptor circle to be a little speck and the resident circle to consume the page, wielding a whip? 4 Does a universally applicable optimum level of size and distance in the resident)preceptor relationship exist? If the optimum varies substantially with the individuals involved, the practical value of the trait will be limited. 5 Do gender or culture differences influence the resident)preceptor relationship? Does the gender or culture of the preceptor interact with that of the resident in this regard? 6 Encouraging psychologically closer relationships between students and instructors can yield unintended consequences. The closer a relationship becomes, the greater the likelihood that it might spill over into the territory of romance. If closer relationships between residents and preceptors are encouraged to improve the instructional experience, clear guidelines are needed to specify their limits. 7 For the sake of generalisability, how does the concept of reducing psychological size and distance relate to an instructor teaching 200 students in an amphitheatre? Is it possible to reduce the psychological size and distance when the instructor is physically distant and sharing his ⁄her presence with 200 others? Some recommendations for giving a good lecture seem directed at reducing the psychological size and distance of the instructor. For example, making one-to-one eye contact with random audience members would seem to be one such strategy.

Bullying and harassment in medical schools

Still rife and must be tackled

Evaluating the outcomes of undergraduate medical education.

Evaluation of the outcomes of undergraduate medical education (UME) is a complex issue, not least because of the time lapse between the educational intervention (the undergraduate curriculum) and the overall outcome (successful performance as an independent medical practitioner). Numerous other variables, including postgraduate education, the clinical practice environment and personal, social and domestic circumstances, all have an impact on professional practice. However, medical educators must try to find ways of evaluating the outcomes of UME, particularly in view of the substantial academic and financial investments made in the course of initiating change over recent years. There is a small but expanding literature in which the relationship between UME and performance as a newly qualified graduate has been used to indicate the success of undergraduate programmes. Traditionally, UME focused on providing the knowledge base thought to be essential for graduating students. Medical schools then handed on their graduates to individual hospitals for their first year of supervised clinical practice. This transition from student to practising doctor is notoriously stressful, a fact usually attributed to the failure of undergraduate schools to equip their students with the wider range of skills and attitudes necessary for independent practice. Some of the problems associated with the transitional period were highlighted recently in a paper illustrating discrepancies between stated undergraduate curricular outcomes and the competency requirements of clinical practice. First year residency directors were asked to state their expectations of graduates’ skills and competencies at entry into their programmes and after 3 months in practice. It was clear that residency directors expected to set aside significant time and resources during the early weeks of their programmes for training in basic skills, at a level that could have been achieved during UME. This leads to the conclusion that better communication and agreement between those who set undergraduate outcomes and residency directors would avoid wasting time in the clinical arena. Interestingly, the majority of the skills cited in this study as being required at 3 months post graduation are also identified in other documents, notably Tomorrow’s Doctors, as being required at completion of UME. Many medical schools worldwide use outcomes set by the General Medical Council or an equivalent body to delineate the skills required at graduation, running an end-ofcourse objective structured clinical examination (OSCE) or similar assessment to establish student competence. Despite this, a recent Danish study showed newly qualified doctors self-reporting poor levels of competence in a range of essential clinical skills. These findings are congruent with our own (as yet unpublished) data, which uses self-reporting and objective assessment to show that new graduates lack both confidence and competence in a range of clinical skills, despite having recently passed qualifying clinical examinations. The discrepancy between UME and early clinical performance is further highlighted by reports of only low–moderate correlations between undergraduate student grades in knowledge-based assessments and performance as first year residents. Two papers in this issue of Medical Education shed more light on the relationship between UME and early clinical performance and examine two of the mainstays of modern UME: communication skills and OSCEs. Willis and colleagues investigated the attitudes of their graduates to communication skills and their teaching in an undergraduate course. They compared the last cohort of pre-registration house officers (PRHOs; equivalent to junior residents) to undertake the traditional curriculum in their medical school with the first cohort of a new course in which communication skills are emphasised. The results suggest that teaching communication skills in UME gives graduates a better cognitive framework for dealing with communication issues, the ability to use more complex communication skills in their daily practice and an appreciation of the therapeutic potential of communication. Probert and colleagues investigated whether the results of a final year OSCE could predict performance as a PRHO more accurately than the results of a traditional long case examination. Pre-registration house officer performance was assessed by selfand consultant assessment. Taking into account the differences in examCorrespondence: Diana F Wood, Deputy Dean for Education, Department of Endocrinology, 5th Floor, King George V Wing, St Bartholomew’s Hospital, London EC1A 7BE, UK. Tel.: 00 44 20 7601 8094; Fax: 00 44 20 7601 8306; E-mail: d.f.wood@qmul.ac.uk Editorial

Mens sana in corpore sano: student well-being and the development of resilience

As time goes by, increasingly one finds oneself reminiscing with like‐minded doctors of a similar age. Somewhat fondly, we remember 100‐hour weeks, one in two on‐call rotas and shifts in the Emergency Department with nothing more to hand than the Guide to Practical Procedures, including helpful line‐drawn diagrams should you have to drain a pericardial effusion with a lumbar puncture needle connected to a single ECG lead. Which you did have to do. ‘That’, we tell ourselves ‘was how to become resilient’, as we potter off to fill in another on‐line assessment for a trainee who has never seen a pericardial effusion drained, never mind done it in the middle of the night with nothing more than a pocket handbook to help. Developing resilience? Well, maybe. Patient safety? Almost certainly compromised.

Not if I was very ill

The proposal that interprofessional education (IPE) might improve teamwork and ultimately enhance patient care has been well rehearsed over the last two decades. Unfortunately, good data to support the proposition remain scanty, despite most people’s intuition that it must be a Good Thing . In Medical Education we have made repeated calls for more and better research in this important area; two papers we publish this month perhaps help to illustrate some of the problems encountered in IPE and lead us to question some of the assumptions that have been made in the field.

Developing A Pragmatic Medical Curriculum for the 21st Century.

Medical education within a hospital setting presents both opportunities and challenges. The range of educational experiences on offer is often vast, though may be lost in the overworked and convoluted environment of a tertiary centre. As our learners are increasingly consumed by the literal and figurative labyrinths of hospitals and electronic learning logs, are we failing to train them in the skills they need to deliver 21st century health care? In response to this problem we propose a FARCICAL approach: Fostering A Relevant Curriculum that Is Closer to Actual Life.