Gillian Maudsley

Promoting professional knowledge, experiential learning and critical thinking for medical students.

It has been recognized internationally that undergraduate medical education must adapt to changing needs, as illustrated by the Tomorrow’s Doctors recommendations from the General Medical Council. This paper aims to relate contemporary educational theory to under‐graduate medical educational requirements, specifically highlighting conditions (e.g. experiential learning) for: professional knowledge acquisition; critical thinking, problem‐solving and clinical problem‐solving; and lifelong professional learning. Furthermore, problem‐based learning (PBL) is highlighted as potentially providing such conditions. There are lessons from contemporary educational theory for the reform of undergraduate medical education. These include valuing prior knowledge and experience; promoting learner responsibility through facilitating rather than directing learning; encouraging learners to test out and apply new knowledge, and using small‐group work to foster explicitly the elusive skills of critical thinking and reflection. Contemporary educational theory contributes valuable insights, but cannot dictate the ultimate ‘mix’; at best it provides some principles for reflective analysis of the learning experiences created for tomorrow’s doctors.

‘Science’, ‘critical thinking’ and ‘competence’ for Tomorrow’s Doctors. A review of terms and concepts

The recommendations of the General Medical Council in Tomorrow’s Doctors renewed efforts to define core knowledge in undergraduate medical education. They also encouraged better use of the medical knowledge base in nurturing clinical judgement, critical thinking, and reflective practice. What then does the medical world understand by ‘science’, ‘critical thinking’ and ‘competence’, given the need to address both growth and uncertainty in the knowledge base and to practise evidence‐based healthcare?

Mixing it but not mixed-up: Mixed methods research in medical education (a critical narrative review)

Background: Some important research questions in medical education and health services research need ‘mixed methods research’ (particularly synthesizing quantitative and qualitative findings). The approach is not new, but should be more explicitly reported. Aim: The broad search question here, of a disjointed literature, was thus: What is mixed methods research – how should it relate to medical education research?, focused on explicit acknowledgement of ‘mixing’. Methods: Literature searching focused on Web of Knowledge supplemented by other databases across disciplines. Findings: Five main messages emerged: – Thinking quantitative and qualitative, not quantitative versus qualitative – Appreciating that mixed methods research blends different knowledge claims, enquiry strategies, and methods – Using a ‘horses for courses’ [whatever works] approach to the question, and clarifying the mix – Appreciating how medical education research competes with the ‘evidence-based’ movement, health services research, and the ‘RCT’ – Being more explicit about the role of mixed methods in medical education research, and the required expertise Conclusion: Mixed methods research is valuable, yet the literature relevant to medical education is fragmented and poorly indexed. The required time, effort, expertise, and techniques deserve better recognition. More write-ups should explicitly discuss the ‘mixing’ (particularly of findings), rather than report separate components.

Cause of death in cerebral palsy: a descriptive study

BACKGROUND Cause specific research on death certification in chronic disease has rarely involved cerebral palsy. AIMS To evaluate cause of death information in people known to have cerebral palsy by: describing the cause of death distribution; determining case ascertainment using death certification as the data source; and analysing the choice of wording and its arrangement in the “cause of death statement”. STUDY CASES AND SETTING People with early or late impairment cerebral palsy who died by 30 June 1998, on the population based Mersey Cerebral Palsy Register born 1966–91 to mothers resident locally. STUDY DESIGN Descriptive study of the multiply coded cause of death statements from National Health Service Central Register flagging. RESULTS Death certificate copies were acquired for all 282 (13.4%) of the 2102 registered cases who died. Cerebral palsy was the most common “underlying cause of death” (95 of 282; 33.7%) and was mentioned in a further 61 cases. The underlying cause of death was more likely to be cerebral palsy with increasingly severe disability and was derived from Part II in 16 of 95 cases. CONCLUSIONS The potential of death certification for case ascertainment of cerebral palsy is important, but limited, even with multiple cause coding. Mortality data need careful interpretation as a proxy source for examining trends and patterns in cerebral palsy.

Public health education for medical students: rising to the professional challenge

Public health competencies, especially as they relate to the management of chronic disease, will be of increasing importance to the global health-care workforce. The General Medical Councils recommendations on basic medical education have helped to entrench the position of public health and related disciplines. Tomorrows Doctors has recently been updated. This article describes the indicative goals that should underpin the development of undergraduate medical education in public health, presented in a national statement. The statement was originally produced on behalf of academic departments of public health and related disciplines in UK medical schools. The dearth of evidence in this field leaves many questions for future educational research.

Medical students’ and prospective medical students’ uncertainties about career intentions: Cross-sectional and longitudinal studies

Background: Policy prompts medical students’ earlier career awareness. Aim: To explore changes and uncertainty in medical (and prospective medical) students’ career intentions in a 5-year problem-based curriculum. Methods: Six postal questionnaire surveys of medical students and one survey of prospective medical students sought career intentions from three entry-cohorts (one also seeking why they chose medicine, and one, the reason for the career intention). Results: From the 973 (91.4%) 2001/02 admission interviewees responding, 74/189 (39.2%) of those admitted and remaining ‘in-year’ re-reported career intentions 5 years later (2006/07). Of the 1999 entrants (start-Year 1; end-Year 1; and mid-Year 3) and 2001 entrants (start-Year 1 and end-Year 1), 61.2–77.9% responded. Up to mid-programme, only 9.5–18.8% reported general practice, significantly more of whom described altruistic reasons for choosing medicine (2001 entrants). Tracked longitudinally, career intentions stayed relatively stable, but a small significant retreat from general practice over Year 1 predated clinical placements. From pre-admission to mid-Year 5, uncertainty decreased significantly, but 14.9% replied ‘do not know’ both times. Significantly more prospective students from the least affluent English or Welsh postcodes specified a career intention. Conclusion: Many students might delay considering career intentions, particularly general practice. Socioeconomic determinants of early medical career decision making merit further study.

Causes of excess mortality in cerebral palsy

‘Causes of excess mortality in cerebral palsy’ SIR–We were interested to read Strauss et al.’s paper reporting causes of excess mortality in cerebral palsy (CP) compared with the general population1. These potentially very important excess ‘causes of death’ included some cancers, and diseases of the circulatory and respiratory systems. A major strength of their study was that the dataset of individuals was very large (n=4028 deaths). Various reasons for the excess mortality were discussed, including possible causal links as well as differential health service use and treatment strategies. If substantiated, such an excess would have major implications for prevention strategies in CP and for addressing inequity in service provision. Before attaching too much credence to the results, however, considerable caution must be applied in interpreting them, because of limitations in the selection methods and data analysis. A major concern is how the cases of CP were selected, i.e. selection bias (affecting the denominator of mortality rates). The dataset from which the sample was drawn comprised 182 263 individuals with developmental disability being evaluated annually, for receipt of services, by a 200item questionnaire, the Client Development Evaluation Report (CDER). CP was identified if three items of the questionnaire (severity, type, and location of CP) ‘indicated presence of [CP]’. This ‘case definition’ was tautological, and lacked specific inclusion and exclusion criteria. It remains unclear how CP itself was defined and how, for each item, the category ‘other/unspecified’ was used. If two items were present, for example, did the authors ignore CP as a diagnosis, even though both items purported to be descriptors of CP? The dataset comprised those who were entitled to receive services from the State of California. Several biases must therefore be considered. The authors acknowledged that those receiving services might have more severe CP than those not entitled, but also very severe cases who died early may never have received services. The approach to case ascertainment was unlikely to be as comprehensive in detecting cases of CP as a prospective population-based CP register. In the Introduction, the authors cited Badawi et al.’s case definition of CP: ‘a group of motor disorders of central origin... As generally understood there must be motor impairment, and this impairment must stem from a malfunction of the brain (rather than spinal cord or muscles)... [the brain malfunction] must be non-progressive and it must be manifest early in life’2. If the operational case definition of CP, implicitly or explicitly, correctly included nonprogression, classifying the sequelae of a progressive brain tumour as non-progressive CP might have been encouraged. This misclassification would confer entitlement to services that might otherwise be forgone. A further concern is information bias, namely classification of the ‘cause of death’ (affecting the numerator of mortality rates). Although the authors did not explicitly identify which component of the Cause of Death statement from the death certificate was analysed, presumably it was the Underlying Cause of Death (i.e. ‘the disease or injury which initiated the train of morbid events leading directly to death’3). According to international convention, when only one element is reported in official mortality statistics, it is the Underlying Cause of Death – as derived from the Cause of Death statement by internationally agreed coding rules (International Classification of Disease [ICD] 9th revision)3. Generally, Strauss et al. used the non-specific term ‘cause of death’ throughout. This term includes the Underlying Cause of Death, Intermediate (Other Antecedent) Cause(s) of Death, Direct (Immediate) Cause of Death, and Contributory Cause(s) of Death. The term Underlying Cause of Death is used for the first time in the penultimate paragraph of the paper (and related table). They stated that 724 (30%) of the 2416 deaths of those aged over 14 years had a ‘cause of death’ (presumably Underlying Cause of Death) ‘uninformative for our purposes’. These comprised infantile CP, congenital anomalies or undefined causes! While respiratory infection may well be the Immediate Cause of Death in people with CP, we would expect CP itself to be the Underlying Cause of Death in a substantial proportion. In our research (282 deaths), this was 34%4. Indeed, Strauss et al.’s data may well have included an approximately similar proportion, but we can only deduce that less than 30% of deaths had CP as the Underlying Cause of Death (because that proportion included congenital anomalies or undefined causes). Strauss et al. hypothesised that all 30% might have had respiratory disease as the Underlying Cause of Death. In the Discussion, Strauss et al. reported their analysis of a second and separate data source, the National Health Interview Survey data for Underlying Cause of Death (+ Contributory Cause[s] of Death), because ‘we do not have access to multiple-cause-of-death data which can be linked to our own’. The nature of this data source or the denominator population size were not revealed, except that the data were extracted for Californians, aged 18 years and over, for 1986 to 1994 (9-year period) with ‘a reference to [CP]’. In a footnote to the table, Strauss reported that ‘7% [had CP] cited as the underlying cause’, much lower than our observation of 34% (for age 0 to 33 years, all causes)4. Their case definition included ICD-9 codes 333.2, 333.7, 342–344, which was reasonably comparable to ours of 343–344 (we had no deaths for the other codes). They ‘identified the 401 individuals whose death certificate included a reference to [CP]’. Relating this to the 4028 individuals stated in the Method as dying during the study period [1986 to 1995, 10year period]’, this gives approximately 10 to 11% of deaths, i.e. much lower than the 55% of deaths that we reported for any mention of CP (not just as Underlying Cause of Death or Contributory Cause[s] of Death)4. A further analytical concern is that the authors stated that they calculated the excess mortality as standardised mortality ratios (SMRs). An SMR is a summary measure combining several observed age-specific numbers expressed as a ratio to the expected number of deaths if the age-specific rates in a standard population applied. The authors’ tabulated ‘SMRs’ were not apparently summary values; rather each was a simple ratio of the observed to the expected number of deaths within a single age-group.